APSF.ORG NEWSLETTER THE OFFICIAL JOURNAL OF THE ANESTHESIA PATIENT SAFETY FOUNDATION

Volume 33, No. 1, 1–32 Circulation 122,210 June 2018

Using the 2018 Guidelines from the Joint Commission to Kickstart Your Hospital’s Program to Reduce Opioid-Induced Ventilatory Impairment by Thomas W. Frederickson, MD, MBA, FACP, SFHM, and JE Lambrecht, MD, PharmD

In the hospital, opioids are the most com- and guidelines designed to reduce OIVI in the monly prescribed class of medications and the inpatient setting. One of the most recent and second most common class of medications comprehensive of these guidelines is The Joint associated with adverse events.1,2 There are a Commission R3 Report issued in August 2017.1 range of adverse events associated with opioid The R3 Report (R3 stands for Rationale, use in the hospital. The most serious of these in Requirement, and Reference) provides stan- terms of patient mortality is opioid-induced ven- tilatory impairment (OIVI). Approximately 1 in dards for inpatient pain assessment and man- 200 hospitalized postoperative surgical agement designed to improve quality and safety. patients suffer from OIVI.3 One report identified The standards focus on safe opioid prescribing 700 inpatient deaths in the U.S. directly attrib- and performance improvement, minimizing treatment risk, and performance monitoring and cians must identify patients who are at high risk uted to patient-controlled analgesia between for developing OIVI. The history and physical 4 improvement using data analysis. This review 2005 and 2009. In addition to being common, exam is the mainstay for gathering important will suggest four specific ways hospitals and their and, at times, devastating to patients and care- and specific knowledge about patients. Risk medical staff can implement some of these stan- givers alike, adverse events related to opioids assessment and preoperative screening by are costly. In a 2011 study, annual costs in the dards to decrease the risk of OIVI. the surgeon, anesthesia professional, hospital- U.S. associated with postoperative OIVI were ist, and primary care physician are all helpful approximately $2 billion.5 The significant impact STRATEGY 1: ASSESSMENT AND and can be used to gain insight for risk assess- of OIVI on patient safety and health care costs MITIGATION OF PATIENT RISK FOR OIVI ment. Comorbid conditions should be noted. has prompted many governmental and non- When caring for postoperative patients and governmental agencies to develop regulations others receiving opioids in the hospital, clini- See “Kickstart,” Page 8

Current Status of Sugammadex Usage and the Occurrence of Sugammadex-Induced Anaphylaxis in Japan by Tomoronori Takazawa, MD, PhD; Katsuyuki Miyasaka, MD, PhD; Tomorhiro Sawa, MD, PhD; Hiroki Iida, MD, PhD Sugammadex is a synthetic cyclodextrin ture of neostigmine and atropine) was used to derivative that encapsulates aminosteroid reverse the effects of muscle relaxants in Japan muscle relaxants, especially rocuronium, to before the release of sugammadex. The inci- reverse their effect. Sugammadex (Bridion®, dence of neostigmine is not exactly elucidated Merck Sharp & Dohme B.V., a subsidiary of in the literature. However, there are only a few Merck & Co., Inc.) was first released in the Euro- isolated case reports despite decades of its rou- pean Union in 2008 and then in Japan in April tine use to reverse neuromuscular blockade. 2010. Sugammadex has been widely used since its release in Japan. Total sales of sugam- See “Sugammadex,” Page 11 madex in Japan reached $51,880,000 in 2010, more than four times that in Spain ($11,376,000), which was second in sales worldwide (data obtained from MSD K.K. (a subsidiary of Merck By Fvasconcellos (Own work) [Public domain], via Wikimedia Commons & Co., Inc.).1 Sugammadex use in Japan has Space-filling model of sugammadex sodium continued to grow with a total of 11,053,680 With this June APSF Newsletter issue, we are vials sold over the seven years since its release sugammadex because multiple vials may be introducing our new APSF logo and branding. During the past few months, the Communica- (© 2018 IQVIA/IMS-JPN (Japan) JPM (Japan used on a single patient. Assuming that only one tions Committee has been working hard to Pharmaceutical Market), calculation based on vial was used in most cases, sugammadex was bring a modern, energetic, new look to reflect JPM from April 2010 to June 2017 (reprinted with administered to approximately 10% of the total our renewed commitment to Patient Safety in permission). It is not possible to accurately count Japanese population during the eight-year Anesthesia. the number of patients who have received period since its release. Atvagoreverse® (a mix-

TABLE OF CONTENTS, NEXT PAGE APSF NEWSLETTER June 2018 PAGE 2

TABLE OF CONTENTS ARTICLES: NEWSLETTER Using the 2018 Guidelines from the Joint Commission to Kickstart Your Hospital’s Program to Reduce Opioid-Induced Ventilatory Impairment...... Cover Current Status of Sugammadex Usage and the Occurrence of Sugammadex-Induced The Official Journal of the Anaphylaxis In Japan...... Cover Anesthesia Patient Safety Foundation With Gratitude to Dr. John Eichhorn: An Anesthesia Patient Safety Innovator...... Page 3 The Anesthesia Patient Safety Foundation Newsletter Planning Prevents Poor Performance: An Approach to Pediatric Airway Management...... Page 4 is the official publication of the nonprofit Anesthesia Can Prescription Drug Monitoring Programs Aid Perioperative Clinicians in Reducing Patient Safety Foundation and is published three Opioid-Induced Ventilatory Impairment?...... Page 14 times per year in Wilmington, Delaware. Individual Safe Gas Systems and Office-Based Anesthesia...... Page 17 subscription–$100, Corpor­ ate–$500.­ Contributions­ Preventing Surgical Site Infection After Cesarean Delivery—The Anesthesia Professional's Role...... Page 25 to the Foundation are tax deduct­ible. Copy­right, Anesthesia Patient Safety Foundation, 2018. Systemic Lidocaine: An Effective and Safe Modality for Postoperative Pain Management and Early Recovery...... Page 28 The opinions expressed in this Newsletter are not necessarily those of the Anesthesia Patient Safety DEAR SIRS: Foundation. The APSF neither writes nor promul- "No Read" Errors Related to Prefilled Syringes...... Page 20 gates standards, and the opinions expressed herein Not All Manifolds are the Same: Lessons in Intravenous Drug Administration...... Page 24 should not be construed to constitute practice stan- Defective Pediatric Endotracheal Tubes (ETTs)...... Page 31 dards or practice parameters. Validity of opinions pre- sented, drug dosages, accuracy, and completeness LETTERS TO THE EDITOR: of content are not guaranteed by the APSF. In Response to “Carbon Dioxide Used as Insufflating Gas May Raise ETCO2 During GI Endoscopy”...... Page 21 APSF Executive Committee 2018: A Bad System Will Beat A Good Person Every Time...... Page 30 Mark A. Warner, MD, President, Rochester, MN; Daniel J. Cole, MD, APSF Vice President, Los Angeles, CA; EDITORIAL: Matthew B. Weinger, MD, Secretary, Nashville, TN; Sugammadex: The Anaphylactic Risk...... Page 13 Douglas A. Bartlett, APSF Treasurer, Boulder, CO; Maria van Pelt, CRNA, PhD, Director At-Large, Boston, MA. APSF ANNOUNCEMENTS: Guide for Authors...... Page 2 APSF Newsletter Editorial Board 2018: Steven B. Greenberg, MD, Editor-in-Chief, Chicago, IL; Save the Date— 2018 Stoelting Conference...... Page 3 Edward A. Bittner, MD, PhD, Associate Editor, Boston, 2018 APSF Trainee Quality Improvement (TQI) Recognition Program...... Page 6 MA; Jennifer M. Banayan, MD, Assistant Editor, Chi- APSF Website Offers Online Educational Videos...... Page 7 cago, IL; Meghan Lane-Fall, MD, Assistant Editor, Corporate Advisory Council...... Page 10 Philadelphia, PA; Joan M. Christie, MD, St. Petersberg, Get Social With Us...... Page 16 FL; Jan Ehrenwerth, MD, New Haven, CT; John H. APSF New Website Announcement...... Page 17 Eichhorn, MD, San Jose, CA; Nikolaus Gravenstein, MD, Gainesville, FL; Joshua Lea, CRNA, Boston, MA; 2018 Corporate Giving Opportunities...... Page 22 Bommy Hong Mershon, MD, Baltimore, MD; Tricia A. APSF Donor Page...... Page 23 Meyer, PharmD, Temple, TX; Glenn S. Murphy, MD, APSF Safety Recognition Award ...... Page 27 Chicago, IL; Brian Thomas, JD, Kansas City, MO; Jef- frey S. Vender, MD, Winnetka, IL; Wilson Somerville, PhD, Editorial Assistant, Winston-Salem, NC. Japa- nese Editorial Board Members: Hiroki Iida, MD, PhD, APSF Newsletter Guide for Authors Gifu, Japan; Katsuyuki Miyasaka, MD, PhD, Tokyo, The APSF Newsletter is the official journal of the Anes- (4) Dear SIRS is the “Safety Information Response Japan; Tomohiro Sawa, MD, PhD, Tokyo, Japan. thesia Patient Safety Foundation. It is widely distributed System.” The purpose of this column is to allow expe- Address all general, contributor, and sub­scription to a variety of anesthesia professionals, perioperative ditious communication of technology-related safety correspondence to: providers, key industry representatives, and risk manag- concerns raised by our readers, with input and Stacey Maxwell, Administrator ers. It is published three times a year (February, June, response from manufacturers and industry represen- Anesthesia Patient Safety Foundation and October). Deadlines for each issue are as follows: tatives. Dr. Jeffrey Feldman, current chair of the Com- Charlton 1-145 1) February Issue: November 15th, 2) June Issue: mittee on Technology, oversees the column and Mayo Clinic March 15th , 3) October Issue: July 15th. The content of coordinates the readers’ inquiries and the response 200 1st Street SW the newsletter typically focuses on anesthesia-related from industry. Rochester, MN 55905 perioperative patient safety. Decisions regarding con- (5) Invited conference reports summarize clinically rel- [email protected] tent and acceptance of submissions for publication are evant anesthesia patient safety topics based on the Address Newsletter editorial comments, questions, the responsibility of the editors. Some submissions may respective conference discussion. Please limit the letters, and suggestions to: go in future issues, even if the deadline is met. At the word count to less than 1000. Steven B. Greenberg, MD Commercial products are not advertised or endorsed by discretion of the editors, submissions may be consid- Editor-in-Chief, APSF Newsletter the APSF Newsletter; however, upon exclusive consid- ered for publication on our APSF website and social [email protected] media pages. eration from the editors, articles about certain novel and Edward A. Bittner, MD, PhD Types of articles include: important safety-related technological advances may be published. The authors should have no commercial Associate Editor, APSF Newsletter (1) Review articles or invited pro-con debates are origi- ties to, or financial interest in, the technology or com- [email protected] nal manuscripts. They should focus on patient safety mercial product. issues and have appropriate referencing (see https:// Jennifer M. Banayan, MD If accepted for publication, copyright for the accepted Assistant Editor, APSF Newsletter www.apsf.org/authors-guide.php). The articles article is transferred to the APSF. Except for copyright, all [email protected] should be limited to 2,000 words with no more than other rights such as for patents, procedures, or pro- Meghan Lane-Fall, MD 25 references. Figures and/or tables are strongly cesses are retained by the author. Permission to repro- encouraged. Assistant Editor, APSF Newsletter duce articles, figures, tables, or content from the APSF [email protected] (2) Q&A articles are anesthesia patient safety questions Newsletter must be obtained from the APSF. Send contributions to: submitted by readers to knowledgeable experts or Individuals and/or entities interested in submitting designated consultants to provide a response. The material for publication should contact the Editor-in- Anesthesia Patient Safety Foundation articles should be limited to 750 words. Chief directly at [email protected]. Please refer to Charlton 1-145 (3) Letters to the editor are welcome and should be lim- the APSF Newsletter link: https://www.apsf.org/ Mayo Clinic ited to 500 words. Please include references when authors-guide.php for detailed information regarding 200 1st St SW Rochester, MN 55905, U.S.A. appropriate. specific requirements for submissions. Or please donate online at www.apsf.org. APSF NEWSLETTER June 2018 PAGE 3

With Gratitude to Dr. John Eichhorn: An Anesthesia Patient Safety Innovator by Mark A. Warner, MD We extend our best wishes and gratitude to thesiology paper was the first to suggest dra- John H. Eichhorn, MD, as he transitions from matic improvement in anesthesia patient safety over three decades of incomparable leader- through the behaviors of continuous intraoper- ship and mentorship roles with APSF and ative monitoring, best implemented by enhanc- within the specialty to finding more time to ing the human senses with early electronic spend with his wonderful wife, Marsha, in warnings from capnography and pulse oxime- retirement. Dr. Eichhorn was part of the original try.1 Dr. Eichhorn chaired the Harvard Anesthe- APSF leadership and was the founding editor sia Risk Management Committee that wrote the of the APSF Newsletter. He led the Newsletter original “Harvard standards” for intraoperative from its inception in 1985 until 2002 and con- monitoring. These standards became the basis tinues to serve on its Editorial Board today. As for many others, including those adopted by APSF’s archivist and in recognition of the foun- the American Society of Anesthesiologists and dation’s 25th anniversary in 2010, Dr. Eichhorn a great many other national societies around created an extensive special Newsletter edi- the world. Work from his International Task tion chronicling the remarkable positive influ- Force on Anesthesia Safety was the basis of the ence that APSF has had on improving standards adopted by the World Federation of anesthesia patient safety. His contributions as Societies of Anaesthesiologists. Dr. Eichhorn is APSF Newsletter founder, editor, and mentor to especially proud of his contribution to the World his successors have made the Newsletter the Health Organization Surgical Safety Checklist. world’s most widely distributed anesthesia Also, his 1986 JAMA journal article describing publication. the creation and adoption of the original moni- John H. Eichhorn, MD toring standards2 was honored in 2015 as Dr. Eichhorn, originally from Cleveland, Ohio, number 10 in an historic compilation published His time in APSF leadership roles is drawing is a graduate of Princeton University and Har- in Anesthesia and Analgesia entitled, “Game to a close, but his efforts and their profound, vard Medical School. After starting in general changers: The 20 most important anesthesia positive impact will continue long into the future. surgery, he switched to anesthesiology resi- articles ever published.”3 dency training at Harvard/Beth Israel Hospital in Dr. Eichhorn has left a remarkable legacy and all There have been many awards and honors Boston. He joined the Harvard faculty in 1979 of us and our patients are better for it. for Dr. Eichhorn in recognition of his contribu- and remained there until moving to Jackson, Dr. Mark Warner is President of the APSF and tions to improving patient safety. For example, Mississippi, in 1991 where he served more than in 2011 the Joint Commission/National Quality the Annenberg Professor of Anesthesiology, a decade as professor and chair of anesthesiol- Forum consortium presented him with the high- Mayo Clinic, Rochester, MN. ogy at the University of Mississippi. He subse- est honor in patient safety, the John M. Eisen- quently transitioned to the University of Ken- Dr. Warner has no disclosures with regards to the berg Award for Individual Achievement in tucky, completing his distinguished career there Patient Safety and Quality. Receiving a number content of the article. and retiring in 2017. of additional career recognition awards in the REFERENCES Dr. Eichhorn’s primary academic interests past decade, he continues to serve the spe- 1. Eichhorn JH: Prevention of intraoperative anesthesia have been in the areas of anesthesia patient cialty and our patients by tenaciously advocat- accidents and related severe injury through safety safety, standards of practice, risk management, ing for practice improvements that lead to monitoring. Anesthesiology 1989;70:572–577. and accident analysis. His landmark 1989 Anes- better patient safety and outcomes. 2. Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient monitoring during anesthesia at Harvard Med- ical School. JAMA 1986;256:1017–1020. SAVE THE DATE Stoelting Conference 3. Barash P, Bieterman K, Hersey D: Game changers: the Royal Palms Resort and Spa, Wed. and Thurs., September 5-6, 2018 20 most important anesthesia articles ever published. Phoenix, AZ Anesth Analg 2015;120:663–670.

Perioperative Medication Safety: Advancing Best Practices 1) What do we know now? The APSF continues to accept 2) What should we do? and appreciate contributions. 3) How should we do it? Send contributions to: Mark A. Warner, MD, President of the APSF, will be the moderator for this conference, which Anesthesia Patient Safety Foundation will include expert presentations and panel discussions. The primary focus of this conference Mark A. Warner, MD, Charlton 1-145 will be achieving consensus about key issues through closely facilitated working groups. If APSF President you have expertise or an interest in helping to advance perioperative medication safety, con- Mayo Clinic sider participating. 200 1st St SW A special thank you If you are interested in attending, please contact Stacey Maxwell, Rochester, MN 55905, U.S.A. to our Stoelting APSF administrator, at [email protected]. Space is limited. Conference Supporters: For more information about the benefits of sponsoring the or donate online at apsf.org conference, please contact Sara Moser at [email protected]. APSF NEWSLETTER June 2018 PAGE 4

Planning Prevents Poor Performance: An Approach to Pediatric Airway Management by Nicholas M. Dalesio, MD

Pediatric airway management remains a sig- Pediatric anatomy and physiology present airway placement during an airway emergency nificant cause for perioperative morbidity and unique challenges during airway management. extremely difficult.6 mortality. Emergencies arising from airway com- A larger occiput in infants and young children While several anatomical differences occur plications constitute 25 to 36% of all reported (< 2–3 years of age) causes neck flexion in between the adult and child airway, some simi- anesthesia closed-claims.1-3 Of those, respira- anesthetized children leading to airway larities in management occur. Adequate ventila- tory events are more common in children (43%) obstruction. tion is paramount. Techniques to improve than in adults (30%), and children suffer a higher Common Pediatric Anatomical Findings: ventilation are similar to those in adults, including mortality rate (50% vs. 35%).1-3 Furthermore, 1) two-handed mask techniques, 2) head tilt, 3) when the airway is difficult, practitioners require 1) a cephalad trachea (the cricothyroid mem- chin lift, 4) jaw thrust, 5) positive pressure, and 6) specialized skills.4 Unlike in adults, the potential brane is parallel to C4 compared to the C6 the use of oro- and nasopharyngeal airways for a difficult airway in children can often be pre- vertebrae in adults) when upper airway obstruction is suspected. dicted, which provides an opportunity for pre- 2) an omega-shaped, “floppy” epiglottis due to Children’s airways come in many more sizes than emptive planning. Thus, untimely deaths can be immature connective tissue at the vallecula adults’ airways,7 necessitating accurate measure- prevented through targeted development of 3) large tongue-to-mouth ratio ments of oro- and nasopharyngeal airways. The anatomic knowledge, specific application of posterior aspect of the tongue can worsen emerging technology, and advanced profi- 4) anteriorly angled vocal cords providing addi- ciency training and educational programs to tional challenges for nonpediatric anesthesia obstruction with an oral airway that is too short, broadly implement the specialized technique of professionals whereas an oral airway that is too long may push pediatric critical airway management. At Johns the epiglottis into the trachea, thus worsening Oxygen consumption is double that of an adult 8 Hopkins Hospital, we have created a multidisci- airway obstruction. Attention to ventilation pres- (6–7 ml/kg/min versus 3–4 ml/kg/min), and func- plinary program to address pediatric airway sures is also important. Aggressive mask venti- tional residual capacity (FRC) decreases substan- lation can lead to gastric insufflation, further management that includes 1) a Pediatric Difficult tially in the supine position, allowing cephalad decreasing FRC and worsening hypoxia. The Airway Response Team (PDART), 2) a Pediatric movement of intra-abdominal contents that supraglottic airway (SGA; a laryngeal mask airway Difficult Airway Consult Service (PDACS), and 3) leads to rapid oxygen desaturation.5 Addition- or LMA is a type of SGA) is another adjuvant that a biannual multidisciplinary pediatric airway ally, hyper-responsive laryngeal reflexes, may improve ventilation. Many SGA subtypes management educational course. Our primary short vocal cord length, and subglottic narrow- goal is to create a service that will mitigate ing may complicate endotracheal tube (ETT) are available and are differentiated based on stress among providers, optimize patient safety, placement. Infants and small children also have their unique attributes including ease of use and 9 and eliminate morbidity associated with pediat- an overriding thyroid cartilage, making external ability to intubate through the internal lumen. ric airway management. airway anatomy indiscernible and surgical See “Pediatric Airway,” Next Page

Figure 1: Retromolar intubation using a Wis-Hipple 1 laryngoscope. The blade is placed in the right retromolar space, bypassing the tongue, and advanced until the epiglottis can be displaced anteriorly to reveal the glottis. APSF NEWSLETTER June 2018 PAGE 5

Managing the Pediatric Difficult Airway From “Pediatric Airway,” Preceding Page gency plans (described as plans A, B, and C) ETT insertion.17,18 Using an SGA as a conduit can Several tools are used for tracheal intubation, based on specific airway conditions are shown allow administration of inhalational anesthesia in Table 1. Patients with these conditions need with the primary technique being direct laryn- and continuous oxygenation and ventilation, to be identified early and before respiratory dis- goscopy. A variety of laryngoscope blades are avoiding hypoxemia in the most vulnerable pedi- tress symptoms occur. It is our practice to available for pediatrics, but because of the atric population. A recent observational study develop and describe airway management anterior trachea and “floppy” epiglottis, many published from data collected via the Multicenter plans within the medical record.13 The pediatric practitioners prefer using a straight (i.e., Miller) Pediatric Difficult Intubation (PeDI) Registry anesthesia team is often best suited to initiate or semi-curved (Wis-Hipple) blade (Figure 1) for reported that overall first-attempt success rates planning for and securing difficult airways children under the age of 5 years.10 were similar for children with a difficult airway should the need arise. If elective airway man- undergoing videolaryngoscopy and those Pediatric difficult airway management can agement is required for elective surgery, these undergoing FOI-SGA, even when controlling for be divided into two categories: unanticipated patients should be cared for at a tertiary care patient factors such as anticipated difficult and anticipated. Fortunately, the unantici- facility, if possible. 19 pated difficult airway in “normal” pediatric airway. The caveat was that FOI-SGA had Though many techniques and devices have patients is rare and often caused by trauma, higher success rates with fewer incidents of been described for difficult airway management, infection, or inexperienced airway practitio- hypoxia in children < 1 year of age, supporting there is a paucity of data showing superiority. In ners. Multiple intubation attempts by experi- the recommendation for continued oxygenation adults, the gold standard is an awake fiberoptic enced pediatric anesthesia professionals during intubation. A cuffed ETT should be used intubation (FOI); however, this procedure is often defined as > 2 attempts, significantly increases when securing a difficult airway in any patient, not possible to perform in small children due to complication rates. Alternative modes for secur- including children,20 because it can compensate poor cooperation.14 Therefore, it is recom- ing the airway should be considered after two for an air leak without exposing patients to risks mended that spontaneous ventilation be main- failed attempts by any practitioner.11 associated with re-intubation. tained during induction of anesthesia and More commonly, the pediatric difficult airway intubation, using medications including inhala- Pediatric difficult airway practice guidelines can be anticipated. Alterations to airway anat- tional anesthetics,5 dexmedetomidine,15 propo- have been described,13,21 primarily adapted omy from genetic, embryologic, or surgical fol,16 and/or ketamine. Ensuring an adequate from the adult difficult airway algorithm.4 Altera- causes can complicate pediatric airway man- depth of anesthesia that prevents laryngospasm tions to the algorithm should focus on the agement. Genetic and craniofacial syndromes during airway manipulation while simultaneously unique attributes of the pediatric airway and that affect the airway are well described in the maintaining spontaneous ventilation requires physiology, replacing only the invasive airway 12 literature, and plans can be formulated prior to advanced skill and practice. Two common tech- management recommendations. For instance, induction of anesthesia. Knowing which device niques to secure the airway include the use of maintaining spontaneous ventilation in children is optimal based on a patient’s specific airway videolaryngoscopes and FOI through a supra- with an anticipated difficult airway is important. anomaly can help with appropriate preparation. glottic airway (FOI-SGA). Videolaryngoscopy has Infants and small children (~ < 20 kg) with high An example of devices and techniques to con- been shown to improve the glottic visualization; oxygen consumption and low FRC especially sider when creating multiple airway contin- however, the technique may increase the time to benefit from this type of management. Sec- ondly, the term “multiple attempts” when Table 1: Endotracheal intubation devices and techniques ranked for success within categories of airway pathology leading to difficult airway management. describing failed intubation should be explicitly defined as more than two, and alternative Upper Airway Craniofacial approaches attempted thereafter. Institutions Obstruction Abnormality Neck Pathology that care for children should have a variety of Small Cervical pediatric ETT sizes readily available and the Visual Mouth Short Soft Tissue Spine value of a SGA use emphasized. Lastly, during Technique Physical (blood) Opening TMD Other (hygroma) Immobile an emergency when the “cannot ventilate, FOI-SGA A A B A A A B cannot intubate” scenario occurs, children FOI alone A — A B A A B under the age of 8 years should undergo needle cricothyrotomy as an invasive surgical Retromolar B — — A B B — technique. Surgical tracheostomies should not Videolaryngoscopy be performed in an emergency in this age 22 Glidescope® C B C A B B A group by non-surgical physicians. Because the thyroid cartilage is overriding and the airway ® C-MAC C B B A B B A anatomy indiscernible via palpation, ultrasound D-Blade* (adolescents) C B C B* B B A guidance for needle cricothyrotomy should be considered, if available.23 Elective Surgical C C C C C — — Airway Facilities that care for children should prepare Table 1: Ranking of endotracheal intubation devices and techniques for difficult airway management in different airway for these emergencies with available rescue pathologies. A = initial/best option; B = secondary option; C = last option; — indicates techniques unlikely to be success- devices and should consider developing a multi- ful or inappropriate for that airway pathology. TD, thyromental distance; FOI-SGA, fiberoptic intubation through supra- disciplinary emergency airway response team. glottic airway; FOI, fiberoptic intubation. *The D-blade has a sharp angled blade, decreasing the length from blade tip to handle. This device may be ideal for older children with large tongues and a short thyromental distance. See “Pediatric Airway,” Next Page APSF NEWSLETTER June 2018 PAGE 6

Pediatric Airway Response Team May Aid Clinicians in Managing Difficult Airways

From “Pediatric Airway,” Preceding Page tered simulated scenarios. Pre- and post-learn- PEDIATRIC DIFFICULT AIRWAY ing is assessed through testing. CONSULT SERVICE (PDACS) We developed a multicomponent Pediatric The PDACS was created to provide airway Difficult Airway Program at Johns Hopkins PEDIATRIC DIFFICULT AIRWAY management plans before an at-risk patient Hospital that consists of a pediatric airway man- RESPONSE TEAM (PDART) develops respiratory distress. Consultation is agement course, the PDART, and the PDACS. The pediatric DART was adapted in Novem- made on either a routine or urgent basis. Rou- The program was created in collaboration with ber 2015 from the adult DART that originated at tine consults are made for patients who have a history of difficult airway but are not experienc- a multitude of pediatric specialists to improve Johns Hopkins in 2008.24 This multidisciplinary ing any respiratory symptoms. If admitting phy- safety and decrease morbidity, stress, and team, composed of pediatric anesthesiologists, urgency associated with airway management sicians and/or nurses obtain information related otolaryngologists, trauma surgeons, respiratory to 1) difficult airway history or 2) any medical in children. therapists, nurses, and pharmacists responds to conditions that potentially alter the structure of a call when initial responders require help with MULTIDISCIPLINARY PEDIATRIC the patient’s face or airway, an electronic page AIRWAY MANAGEMENT COURSE airway management or a child with a difficult goes to the pediatric anesthesiologist to com- airway requires airway management. Pediatric plete the consultation. Urgent consultations are The multidisciplinary pediatric airway course made if children with a history of or potential for is designed to teach practitioners from all anesthesiology attendings facilitate the PDART by staying in-house 24 hours per day, 7 days per difficult airway management shows signs of pediatric disciplines the basics of airway man- early respiratory distress, but immediate inter- week. Emergency airway backpacks are agement, as well as advanced skills needed to vention is not needed. An urgent consult is stocked and carried to each PDART call by the manage different airway scenarios in infants made by a direct phone call to the pediatric and children. Since 2014, this biannual course pediatric anesthesiologist. The backpack houses anesthesiologist and completed within the has instructed residents and fellows, nurses, laryngoscopes, SGAs, and materials for needle hour. If the patient has a difficult airway, a respiratory therapists, paramedics, and other cricothyrotomy. If additional equipment is consultation is complete when 1) a consult note clinicians who want to improve their pediatric needed, such as a flexible bronchoscope, is placed in the patient’s chart, 2) “Difficult airway management skills. After a few didactic patients are mobilized (if possible) to the operat- Airway” is added to the patient’s Problem List, lectures, participants practice using various ing room. Videolaryngoscopes and flexible vid- triggering a banner alert in the patient’s medical ventilation and intubation devices via hands-on eobronchscopes are kept in one location for record, 3) ventilation and intubation plans are skill stations and engage in commonly encoun- easy access within the operating room. See “Pediatric Airway,” Next Page

2018 APSF Trainee Quality Improvement (TQI) Recognition Program The project submission deadline for: • Resident Physician Anesthesiologists is August 31, 2018, at 11:59 pm • Student Registered Nurse Anesthetists is July 15, 2018, at 11:59 pm • Anesthesiologist Assistant Graduate Students is August 31, 2018, at 11:59 pm The APSF Committee on Education and Training announces the third annual and expanded APSF Trainee Quality Improvement Program. The 2018 program hosts tracks for resident physician anesthesiologists, student registered nurse anesthetists and anesthesiologist assistant graduate stu- dents. The APSF invites all US and Canadian anesthesia professionals in training to demonstrate their program’s work in patient safety and QI initia- tives. The top two projects in each track will receive APSF recognition and financial rewards of $1,000 and $500, respectively. All submissions will consist of a video describing the QI project. All video abstract submissions will be created on a mobile device (example, iPhone or iPad). The APSF will accept up to two completed submissions from each US and Canadian training program in each specialty track.

The submission process: • Create a video showcasing your patient safety and quality improvement innovation • Go online to www.dropbox.com and create an account • Upload the video to the Dropbox account and share the file with the email address [email protected] • Send a brief email notification of your completed submission to the APSF Trainee QI Committee at [email protected]. The committee will promptly review your material and acknowledge receipt. Resident Physician and Anesthesiologist Assistant Graduate Students winners will be announced at the 2018 Annual Meeting of the American Society of Anesthesiologists and Student Registered Nurse Anesthetists winners will be announced at the 2018 Nurse Anesthesia Annual Con- gress. The winning entries will also be showcased on the APSF website. Please email any inquiries to [email protected]. For more information please go to: Foundation—Announcements https://www.apsf.org/announcements.php?id=94 APSF NEWSLETTER June 2018 PAGE 7

Expert Personnel and Specialty Equipment Aid in Securing the Pediatric Difficult Airway

From “Pediatric Airway,” Preceding Page 12. Raj D, Luginbuehl I. Managing the difficult airway in Dr. Nicholas Dalesio does not have any disclosures the syndromic child. Continuing Education in Anaes- summarized within the patient’s Problem List with regards to the content of the article. thesia, Critical Care & Pain 2015;15:7–13. and hand-written at the patient’s bedside, 4) a 13. Marín PCE, Engelhardt T. Algorithm for difficult “Difficult Airway” bracelet is placed on the Special acknowledgment to Dr. Luke Janik for airway management in pediatrics. Colombian Jour- serving as a guest editor of this article. Dr. Janik is nal of Anesthesiology 2014;42:325–334. patient, and 5) a “DART” identification card is a pediatric anesthesiologist at NorthShore 14. Murphy T, Howes B. Current practice for awake placed on the patient’s hospital room door. University HealthSystem, Chicago, IL. fibreoptic intubation—some unanswered questions. Anaesthesia 2017;72:678–681. CONCLUSION 15. Mason KP, Lerman J. Review article: Dexmedetomi- REFERENCES dine in children: current knowledge and future appli- Airway management in children, with an 1. Morray JP, Geiduschek JM, Caplan RA, et al. A com- cations. Anesth Analg 2011;113:1129–1142. unanticipated difficult airway requires prior strat- parison of pediatric and adult anesthesia closed mal- 16. Blanco G, Melman E, Cuairan V, et al. Fibreoptic practice claims. Anesthesiology 1993;78:461–467. egy implementation consisting of emergency nasal intubation in children with anticipated and 2. Jimenez N, Posner KL, Cheney FW, et al. An update unanticipated difficult intubation. Paediatr Anaesth response by expert personnel as well as spe- on pediatric anesthesia liability: a closed claims anal- 2001;11:49–53. Anesth Analg cialty equipment including the SGA to be read- ysis. 2007;104:147–153. 17. Fiadjoe JE, Gurnaney H, Dalesio N, et al. A prospec- ily available. Children with an anticipated 3. Bhananker SM, Ramamoorthy C, Geiduschek JM, et tive randomized equivalence trial of the GlideScope al. Anesthesia-related cardiac arrest in children: Cobalt® video laryngoscope to traditional direct difficult airway should have structured airway update from the Pediatric Perioperative Cardiac laryngoscopy in neonates and infants. Anesthesiol- management plans, labeled with appropriate Arrest Registry. Anesth Analg 2007;105:344–350. ogy 2012;116:622–628. alerts in the medical record, and undergo 4. Apfelbaum JL, Nickinovich DG, Hagberg CA, et al. 18. Sun Y, Lu Y, Huang Y, et al. Pediatric video laryngo- Practice guidelines for management of the difficult airway management by experts with extensive scope versus direct laryngoscope: a meta-analysis airway. Anesthesiology 2013;118:251–270. of randomized controlled trials. Cote C, ed. Pediatric pediatric airway experience. Continuing edu- 5. Bhananker S, Harless J, Ramaiah R. Pediatric airway Anesthesia 2014;24:1056–1065. cation, including simulation of emergency situ- management. Int J Crit Illn Inj Sci 2014;4:65–67. 19. Burjek NE, Nishisaki A, Fiadjoe JE, et al. Videolaryn- ations, may help to maintain skills required for 6. Prakash M, Johnny JC. What’s special in a child’s goscopy versus fiber-optic intubation through a larynx? J Pharm Bioallied Sci 2015;7:S55–S58. supraglottic airway in children with a difficult airway: difficult airway management in children. More 7. Brambrink AM, Braun U. Airway management in An analysis from the Multicenter Pediatric Difficult investigation is forthcoming as to whether the infants and children. Best Pract Res Clin Anaesthe- Intubation Registry. Anesthesiology 2017;127:1–9. programs we and others have implemented siol 2005;19:675–697. 20. Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: the reduce adverse events related to the pediatric 8. Coté CJ, Lerman J, Anderson B.. A practice of anes- thesia for infants and children. W.B. Saunders Com- debate should finally end. Anesthesiology 2013; airway. pany; 1993; 308–9. 118:500–501. 21. Weiss M, Engelhardt T. Proposal for the manage- Dr. Nicholas M Dalesio is an Assistant Profes- 9. Kleine-Brueggeney M, Gottfried A, Nabecker S, et al. Pediatric supraglottic airway devices in clinical prac- ment of the unexpected difficult pediatric airway. sor of Anesthesiology at Johns Hopkins Univer- tice: A prospective observational study. BMC Anes- Pediatric Anesthesia 2010;20:454–464. sity Medical School and is in the Department of thesiology 2017;17:119. 22. Coté CJ, Hartnick CJ. Pediatric transtracheal and cri- Anesthesiology/ Division of Pediatric Anesthesiol- 10. Doherty JS, Froom SR, Gildersleve CD. Pediatric cothyrotomy airway devices for emergency use: laryngoscopes and intubation aids old and new. which are appropriate for infants and children? Pae- ogy & Critical Care Medicine. Dr. Dalesio also has Pediatric Anesthesia 2009;19:30–37. diatr Anaesth 2009;19 Suppl 1:66–76. an appointment in the Department of Otolaryn- 11. Fiadjoe, JE, Nishisaki, A, Jagannathan, N, et al. 23. Dalesio NM, Kattail D, Ishman SL, et al. Ultrasound gology/Head & Neck Surgery practicing at the Airway management complications in children with use in the pediatric airway. A & A Case Reports difficult tracheal intubation from the Pediatric Diffi- 2014;2:23–26. Johns Hopkins Bloomberg Children’s Hospital, cult Intubation (PeDI) Registry: a prospective cohort 24. Mark LJ, Herzer KR, Cover R, et al. Difficult airway Baltimore, MD. analysis. The Lancet Respiratory 2015;4:37–48. response team. Anesth Analg 2015;121:127–139.

APSF Website Offers Online Educational Videos Visit the APSF website (www.apsf.org) to view the following Videos

Opioid-Induced Ventilatory Perioperative Visual Loss APSF Presents Simulated APSF Presents Prevention and Impairment (OIVI): Time for a (POVL): Risk Factors and Informed Consent Scenarios for Management of Operating Change in the Monitoring Evolving Management Patients at Risk for Perioperative Room Fires (18 minutes) Strategy for Postoperative PCA Strategies (10 minutes) Visual Loss from Ischemic Optic Patients (7 minutes) Neuropathy (18 minutes) APSF NEWSLETTER June 2018 PAGE 8

Joint Commission Emphasizes Pain Assessment and Monitoring Treatment Risk From “Kickstart,” Cover Page The Society of Hospital Medicine (SHM) cur- Table 1: Risk Factors for Opioid-Induced Current use or previous exposure and response rently has a mentored implementation program Ventilatory Impairment (OIVI) to opioids is also important to document, includ- to institute hospital-wide risk reduction and One or more of these risk factors indicate ing a history of chronic opioid efficacy or toler- patient safety improvement for patients receiv- patients are at increased risk: ance, or of opioid-related adverse events. The ing opioids (Reducing Adverse Drug Events due history should also note chronic use of other to Opioids or RADEO).6 Experienced mentors Age >55 sedative medications such as benzodiazepines are provided by SHM. These quality improve- Obesity (e.g., body mass index ≥ 30 kg/m2) and muscle relaxants. Risk also depends upon ment and pain control experts help coach hospi- Untreated obstructive sleep apnea the type of surgery the patient will have and tal-based teams to improve the quality and expected intensity and duration of postopera- safety of opioid prescribing and administration at History of snoring or witnessed apneas tive pain. their hospitals. This study is evaluating a number Excessive daytime sleepiness Risk assessment is particularly difficult. Even of risk assessment strategies and risk mitigation Neck circumference ≥44.45 cm approaches. Among these approaches are pre- though specific risk factors for OIVI are well Preexisting pulmonary or cardiac disease or described (Table 1), there is not a validated and operative STOP-BANG (Figure 1) screening for dysfunction, e.g., chronic obstructive comprehensive risk scoring system for OIVI in obstructive sleep apnea with triage to postoper- pulmonary disease, congestive heart failure the perioperative setting. Adding to this com- ative continuous positive airway pressure or Smoker (>20 pack-years) ventilation monitoring as appropriate. Electronic plexity is that every patient is at risk. Patients American Society of Anesthesiologists patient who are opioid tolerant are at risk due to the health record (EHR) alerts based on age and status classification 3-5 renal failure, and pharmacy screening for spe- potential difficulty with pain control and the Concomitant administration of sedating agents, need to escalate dosages. Opioid naïve cific high-risk patients, medications, or medica- such as benzodiazepines or antihistamines tion combinations are also being evaluated. patients are also at significant risk because of Continuous opioid infusion in opioid-naïve unpredictable responses to the initial dosages. At present, there is no single comprehensive patients, e.g., IV PCA (Patient-Controlled Analgesia) with basal rate The Joint Commission Standards as outlined strategy that can determine patient risk with OIVI in the R3 Report require that every patient’s pain with 100% accuracy. However, based on an anal- First 24 hours of opioid therapy, e.g., first 24 ysis of challenges that your institution faces, our hours after surgery is a high-risk period for treatment is assessed and monitored in terms surgical patients of both effectiveness and treatment risk. A recommendation is that all hospitals have a risk team-based approach to risk assessment and assessment and mitigation strategy to decrease Prolonged surgery (>2 hours) mitigation should include roles for physicians, OIVI that is team-based, measured, monitored, Thoracic and other large incisions that may nurses and respiratory therapists, and could and adjusted based on your outcomes. interfere with adequate ventilation include alerts and risk scores for the most Large single bolus techniques STRATEGY 2: PRESCRIBING common and serious risk factors, including Naloxone administration: Patients given patients that are opioid naïve, those with renal GUIDELINES AND STANDARDS naloxone are at higher risk for additional 3 failure, co-administration of other sedating The Joint Commissions R Report requires episodes of respiratory depression medications, patient-controlled analgesia (PCA) that hospitals have available non-pharmaco- use, the elderly, and the obese. logic pain treatment modalities and that pain Increased opioid dose requirement: treatment plans be based on the patient’s his- Opioid-naïve patients receiving >10 mg of Figure 1: STOP-BANG11 tory, clinical condition, and the goals of care. In morphine or equivalent in post anesthesia care addition, there are other elements that should unit (PACU) 1. Snoring—Do you snore loudly? be considered in developing prescribing prac- Opioid-tolerant patients who require a 2. Tired—Do you often have daytime tired- tices within an institution. significant amount of opioid in addition to their ness, fatigue or sleepiness? usual daily dosing, e.g., the patient who takes We suggest the following: an opioid analgesic before surgery for 3. Observed—Has anyone seen you stop 1. Clearly identify which clinical provider is persistent pain and received several IV opioid breathing while you sleep? bolus doses in the PACU followed by high- responsible for pain management, particu- dose IV PCA postoperatively 4. Blood Pressure—Do you have or are larly postoperative pain. Agreement between you being treated for high blood pres- specialties at a service line level needs to be Adapted from Pasero C, McCaffery M. Pain assessment and pharmacologic management. St. Louis: Mosby, sure? in place and understood by the patient, nurs- 2011, p.516. 5. BMI >35 kg/m2? ing staff, and the pharmacy. The clinical pro- 6. Age >50 years? vider responsible for pain management may 7. Neck Circumference >40 cm differ based on location in the hospital—i.e., 3. The use of standardized order sets that ED (ED physician), PACU (anesthesia profes- 8. Gender—Male? include nonpharmacological and multimodal sional), ICU (intensivist), and medical/surgical Answering YES to three or more of these eight approaches should be encouraged, or, ideally, questions puts the patient at HIGH risk for obstructive floor (hospitalist or surgeon). required. This is especially important when sleep apnea (OSA). If yes to less than three items then the patient is LOW risk. 2. Standardized handoffs should include all using PCA. Order sets should comply with up- 11 Adapted from: Chung F, Abdullah HR, Liao P. STOP- recent (within the last 4 hours, or 24 hours for to-date prescribing safety standards and give Bang Questionnaire: a practical approach to screen long-acting or extended-release opioids) clear prescribing instructions and parameters. for obstructive sleep apnea. Chest 2016;149:631–8. opioid dosage administrations. See “Kickstart,” Next Page APSF NEWSLETTER June 2018 PAGE 9

Potential Components of a Pain Medication Prescribing Practice Program From “Kickstart,” Preceding Page We recommend a number of best practices: 4. Every patient receiving opioids should have regular nursing assessments of the level of For example, the maximum dosage with a 1. Seventy-five percent of the OIVI events 8 sedation at appropriate intervals including after range should only be two times, and not more occur within the first 24 hours after surgery. dosing of an opioid. Level of sedation should than four times the smallest dose, and orders Consequently, clinicians should especially be assessed approximately 15 minutes after should indicate whether the medication is to focus on risk during this time period, includ- be used for mild, moderate, or severe pain. ing consideration of ventilation monitoring dosage of IV opioids, and 30 minutes for PO Intervals should be long enough to avoid plus pulse oximetry for patients receiving opi- administration. The most common sedation “dose stacking.” Pharmacists should review oids, especially those with, or at risk for, scale used to assess the sedating effects of sleep-disordered breathing. opioids is the Pasero Opioid-induced Sedation and approve all order sets. 10 2. The APSF suggests using continuous moni- Scale (POSS). POSS is a part of the nursing 4. Most hospitalized patients should have a toring of oxygenation and ventilation in flow sheet in most EHRs (Figure 2). The seda- scheduled pain medication if continuous pain patients receiving PCA or neuraxial opioids in tion scale, pain score, and nursing judgment is anticipated. Scheduled pain medications the postoperative period.9 and observation of functional assessment are also necessary for patients chronically should be used by nursing to make decisions 3. The ongoing assessment of pain should not receiving opioids to avoid opioid withdrawal. about administering PRN or scheduled opioids solely be based on numeric (1–10) or subjec- Scheduled pain medications can be non-opi- as well as other sedating medications. oid if the patient is not opioid-habituated. tive (mild, moderate, severe) scales. Pain assessments should include functional crite- 5. Hospital providers who develop protocols that 5. Every patient with acute pain receiving ria that tie to the goals of care for the incorporate continuous monitoring with oxim- opioid medications should have an opioid patient—for example, the ability to mobilize etry and capnography should recognize the de-escalation strategy in place. Opioid and the ability to sleep. Pain assessments benefits and limitations of these monitors and de-escalation can be imbedded in order sets, should also be based on nursing judgment recognize the real dangers of alarm fatigue based on policies and alerts that require daily as well as patient input and goals of care. and the difficulty of setting alarm thresholds re-ordering, or based on pharmacist review that are clinically meaningful. and recommendations. Opioid orders that are not time limited should be avoided altogether. Figure 2: Pasero Opioid-induced STRATEGY 4: ENGAGING Sedation Scale (POSS) THE MEDICAL STAFF STRATEGY 3: PATIENT ASSESSMENT Institutional support is critical to the success AND MONITORING STANDARDS S = Sleep, easy to arouse of any process or practice in your hospital, Much like risk assessment, there is a lack of Acceptable; no action required; may including implementing The Joint Commis- clear evidence for optimal monitoring strategies increase opioid dose as indicated. sion’s opioid safety standards. Support must of patients receiving opioids. The Joint Com- occur at all levels. An executive sponsor for an 1 1. Awake and alert mission standards require the following. Acceptable; no action required; may “opioid safe practices committee” should help 1. Provider access to state-run Prescription increase opioid dose as indicated. establish governance and develop a project Drug Monitoring Programs (PDMPs) and charter that is aligned with the mission and 2. Slightly drowsy, easily aroused vision of the hospital. In addition, the executive Databases. Acceptable; no action required; may 2. Access to monitoring devices such as pulse increase opioid dose if needed. sponsor is essential in garnering necessary oximetry or capnography as deemed neces- resources such as a project budget, purchasing 3. Frequently drowsy, arousable, drifts sary by hospital admistration and medical capital, project management, dedicated clini- off to sleep during conversation cian time, clerical support, and providing infor- staff jointly. Unacceptable; monitor for respiratory mation technology (IT), data collection, and data depression and sedation level closely until 3. Hospitals have standards for screening, analysis personnel. assessing, and reassessing pain that are sedation level is stable at less than 3 and appropriate for the patient’s age, condition, respiratory status is adequate; decrease Changes in clinical practice should be opioid dose 25% to 50% or notify prescriber and cognitive status. designed by front-line clinical staff and or anesthesia professional for orders; con- facilitated by medical staff leadership and 4. Each patient’s pain management plan is sider administering a nonsedating, opioid- administration. This is best achieved via a multi- patient-centered, based on realistic and mea- sparing nonopioid, such as acetaminophen disciplinary committee involving physicians surable expectations, based on treatment or an NSAID, if not contraindicated. from different specialties, nursing, quality objectives, and is paired with patient and/or 4. Somnolent, minimal or no response to improvement staff, pharmacy, and IT person- family education. verbal or physical stimulation nel. In addition, The Joint Commission requires In addition, the Centers for Medicare & Med- Unacceptable; stop opioid; consider that the medical staff are involved in an ongo- administering naloxone, notify prescriber icaid Services (CMS) requires an assessment of ing quality improvement effort, including or anesthesia professional; monitor for risk for postoperative patients receiving IV opi- establishing metrics and analyzing data. oids based on the frequency of dosing, mode respiratory depression and sedation level of delivery, and duration of IV opioid therapy. In closely until sedation level is stable at less It is our opinion that a respected physician addition, hospitals must address what is to be than 3 and respiratory status is adequate. champion is critical for success. This physi- monitored, how frequently (based on risk), Adapted from Pacero C. Acute pain service policy cian can lead your committee and be the and procedure manual, Los Angeles: CA, Academy face of this effort to the medical staff. progress towards goals, side effects, and Medical Systems; 1994. adverse events.7 See “Kickstart,” Next Page APSF NEWSLETTER June 2018 PAGE 10

Key Elements in Developing an Opioid Safety Program

From “Kickstart,” Preceding Page opioid prescribing and administration safety plan. An important role of this champion or other phy- We recommend that hospital administration and sician leaders is medical staff education which medical staff leadership embrace these stan- ANESTHESIA PATIENT SAFETY can occur via grand rounds or other methods dards, not simply to be in compliance, but as FOUNDATION that are effective in your hospital. Ideally this an opportunity to improve the safety of opioid Corporate Advisory champion will also have the political savvy to prescribing and administration within the hospital help get support for needed changes. and reduce the risk of OIVI. Council Some further keys to engaging your medical Dr. Frederickson is Medical Director of Hospi- (as of March 30, 2018) staff are tal Medicine at CHI Health in Omaha, NE, and an 1. Have a statement of purpose. It should be Assistant Clinical Professor of Medicine at the brief, coherent, and easily understood by Creighton University School of Medicine. Mark A Warner, Chair interested parties. The statement of purpose APSF President Dr. Lambrecht is an Assistant Professor of Medi- explains why the opioid safety efforts are cine at the Creighton University School of Medicine Sara Moser valuable to your hospital. An example of such and a staff hospitalist at CHI Health Creighton Uni- a statement would be, “In 2019 and thereaf- APSF Director of Development versity Medical Center–Bergan Mercy. ter in our hospital we will have no serious Becton-Dickinson adverse events related to opioids.” Both authors have no disclosures to report. Idal Beer, MD 2. Recognize that not everyone will initially be on board with the opioid safety program. REFERENCES David Swenson, RPh Anticipate concerns and provide answers. 1. Guidelines: Joint Commission enhances pain assess- ClearLine MD Help everyone see the value in this work. ment and management requirements for accredited Tactics include both sharing data and patient hospitals. The Joint Commission Perspectives Ann Bilyew 2017;37:1-4. Available at https://www.jointcommis- safety stories. Get everyone to understand sion.org/assets/1/18/Joint_Commission_Enhances_ Fresenius Kabi, USA that their commitment really matters to Pain_Assessment_and_Management_Require- Alice Romie, PharmD patient care. ments_for_Accredited_Hospitals1.PDF Accessed March 2018. Angie Lindsey 3. Identify key stakeholders and involve them 2. Davies EC, Green CF, Taylor S, et al. Adverse drug early and gain their support. These are the reactions in hospital in-patients: A prospective analy- GE Healthcare individuals that will be needed in order to sis of 3695 patient-episodes. PLoS One 2009;4: ensure the success of the project and also E4439. Brandon Henak motivate and engage others. They will also 3. Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Tim McCormick provide valuable feedback and help formu- Anesthesiology 2010;112:226–238. late strategies for needed change. 4. Association for the advancement of medical instru- ICU Medical 4. Measure your baseline performance and set mentation. Infusing patients safely: priority issues from JW Beard, MD achievable and measurable objectives. the AAMI/FDA Infusion Device Summit. 2010;1–39. 5. Reed K, May R. HealthGrades patient safety in Ameri- Scott Seewald Develop a scorecard to evaluate progress. can hospitals study. HealthGrades March 2011;5:1–34. Data should be transparent and reported 6. www.hospitalmedicine.org/clinical-topics/opioid- Masimo broadly. safety/. Accessed March 2018. Steve Barker, MD 5. Develop a trusting environment. One key is 7. Center for Clinical Standards and Quality/Survey & not asking staff to increase their workload in Certification Group. Memorandum for requirements Medtronic for hospital medication administration, particularly Patricia Reilly, CRNA order to participate on the project. intravenous (IV) medications and postoperative care of patients receiving IV opioids. Center for Medicare 6. Focus on change management, keeping in Erich Faust mind that changes are easier when they are and Medicaid Services. March 14, 2014. https://www. cms.gov/Medicare/Provider-Enrollment-and-Certifi- imbedded in existing clinical workflows. In cation/SurveyCertificationGenInfo/Downloads/Sur- Omnicell addition, data collection can be taxing— vey-and-Cert-Letter-14-15.pdf. Accessed March, 2018. Tae K. Kwak, PharmD when designing interventions that will be 8. Jungquist CR, Smith K, Nicely KLW, et al. Monitoring measured, keep in mind the time associated hospitalized adult patients for opioid-induced seda- PharMEDium Services with data collection. tion and respiratory depression. Am J Nurs 2017;117: Susan Stolz S27–S35. CONCLUSION 9. Weinger MB, Lee LA. No patient shall be harmed by Leigh Briscoe-Dwyer opioid-induced respiratory depression. APSF News- OIVI leading to respiratory failure and death is letter 2011:26:21–40. https://www.apsf.org/newslet- Preferred Physicians Medical Risk preventable. Opioid-related adverse events ters/html/2011/fall/01_opioid.htm provide opportunities to reflect on current prac- 10. Pasero Opioid-Induced Sedation Scale (POSS) Retention Group tices and institute systems and behavioral [Online]. Available: https://www.ihatoday.org/upload- Steven R. Sanford, JD changes that will improve outcomes and pro- Docs/1/paseroopioidscale.pdf. Accessed August 5, 2015. Brian Thomas, JD duce safer patient care. The Joint Commission R3 11. Chung F, Abdullah HR, Liao P. STOP-Bang Question- report and associated standards require all naire: a practical approach to screen for obstructive accredited hospitals to have a comprehensive sleep apnea. Chest 2016;149:631–8. APSF NEWSLETTER June 2018 PAGE 11

Incidence of Sugammadex Anaphylaxis May Be Similiar to Succinylcholine and Rocuronium

From “Sugammadex,” Cover Page Figure 1: Comparison of the incidence of anaphylaxis to sugammadex, While a dose of Atvagoreverse® (6 ml) costs succinylcholine, and rocuronium. about $6 US Dollars, a 200 mg dose of sugam- 0.06 madex costs about $90. Despite this enormous difference in price, sugammadex has rapidly 0.05 become popular due to its reliability in revers- ing the effects of aminosteroid muscle relax- ants. Other contributing factors for its wide use 0.04 in Japan include unique features of Japan’s nationwide health insurance system that sub- 0.03 stantially reduces the patient’s financial burden and the aggressive promotion by the local 0.03 pharmaceutical company. Consequently, many Japanese anesthesia professionals are unlikely 0.01 to consider price when they select drugs to use Incidence of anaphylaxis (%) during anesthesia. 0.00 There have been several reports on anaphy- laxis caused by sugammadex in Japan.1-4 PMDA JSA Miyazaki Reddy et al. et al. According to the adverse events database of the Sugammadex SUCC ROC Japanese Pharmaceuticals and Medical Devices Agency (PMDA—an agency similar to the Food PMDA: Pharmaceuticals and Medical Devices Agency JSA: Japanese Society of Anesthesiologists and Drug Administration that handles pharma- SUCC: succinylcholine ceuticals and medical devices), 284 cases of ROC: rocuronium sugammadex-induced anaphylaxis were 0.0029%).6 This estimate is close to the number madex-induced anaphylaxis occurred within reported between April 2010 and June 2017. Of obtained from the PMDA database (Figure 1). five to ten minutes after administration in 50 these cases, 268 cases were reported by MSD, This similarity in the PMDA and JSA estimates is (65.8%) and 66 (86.8%) cases, respectively, while the remaining 16 cases were reported not unexpected since the data used were among a total of 76 cases of sugammadex- directly by medical institutions. In accordance largely based on the same source, i.e., reports induced anaphylaxis, who had a confirmed with government regulations, all the cases from MSD. However, it is unclear whether the onset time.6 This is in contrast to a recent reported by MSD were critical, while the cases incidence of sugammadex-induced anaphy- review of sugammadex-induced anaphylaxis reported directly by medical institutions included laxis can be accurately estimated from these noncritical cases. Of the total 284 cases, there which reported that the slowest onset was four data because it is unlikely these reports minutes and the mean value was approximately were 157 cases reported as anaphylactic shock, capture all cases of anaphylaxis. In a recent 88 cases reported as an anaphylactic reaction, 4 two minutes after the administration of sugam- Japanese single-center study, six cases of madex.9 Sugammadex is often administered cases reported as anaphylactoid shock, and 35 anaphylaxis were suspected to be caused by cases as an anaphylactoid reaction. The variety after the end of surgery before extubation, but sugammadex during a three-year study sugammadex-induced anaphylaxis may occur of names used to describe allergic reactions in period. This study estimated the incidence of the reports are likely due to variations in the defi- after extubation. Reported symptoms of sugam- sugammadex-induced anaphylaxis to be madex-induced anaphylaxis are commonly nition of anaphylaxis in Japan. In the past, allergic approximately 1 in 2,500 cases (0.039%) based respiratory system-related, including edema of events involving IgE were called anaphylaxis, on a study population of 15,479 patients.7 The the airway and bronchospasm. Decreases in while those not involving IgE were called ana- authors of this Japanese study referred to a arterial oxygen saturation are reported in about phylactoid reactions. The use of the term “ana- previous observational study reported from 5 half of the cases of sugammadex-induced ana- phylactoid reaction” is no longer recommended. two institutions in New Zealand, showing that phylaxis.9 When severe respiratory symptoms Based on the number of PMDA reported cases the estimated incidence of anaphylaxis due to and total number of doses sold, the incidence of succinylcholine and rocuronium was 0.048% appear after extubation, reintubation or other sugammadex-induced anaphylaxis is estimated and 0.04%, respectively.8 The authors of the supportive treatment may be necessary. If the to be approximately 1 in 40,000 cases (0.0025%). former study concluded that the incidence of discovery of the symptoms is delayed, the patient’s life may be at a severe risk. In facilities According to data from the Japanese Society sugammadex-induced anaphylaxis is roughly that transfer patients to the PACU, ICU, or other of Anesthesiologists (JSA) reported in June equivalent to that of succinylcholine- and 7 wards immediately after extubation, there may 2013 (based on reports from MSD), 95 cases of rocuronium-induced anaphylaxis (Figure 1). It be a period when patients are not monitored sugammadex-induced anaphylaxis (no mortal- is important to note that the incidence of closely, which could delay diagnosis and treat- ity) occurred from April 2010 to October 2013.6 sugammadex-induced anaphylaxis was ment.6 Therefore, patients who are adminis- Based on the number of patients who were approximately 13 times higher than that tered sugammadex should be observed estimated to have received sugammadex reported by PMDA and JSA studies. carefully in the operating room for at least five during the survey period (3.09 million patients), Of the 95 cases of anaphylaxis reported by minutes after administration. In addition, they the incidence of sugammadex-induced ana- the JSA, 76 cases clearly showed an onset time should be monitored closely during transport. phylaxis was calculated to be approximately 29 for sugammadex-induced anaphylaxis. The for every 1 million administrations (1:34,483, JSA study suggested that the onset of sugam- See “Sugammadex,” Next Page APSF NEWSLETTER June 2018 PAGE 12

Sugammadex Anaphlyaxis May Occur Post-Extubation From “Sugammadex,” Preceding Page Figure 2: Drugs that cause anaphylaxis madex-induced anaphylaxis in Japan and A definitive diagnosis of anaphylaxis must in the perioperative period. worldwide. satisfy the following conditions: presence of the Sugammadex has rapidly gained popularity clinical diagnostic criteria of anaphylaxis, high Propofol 5% Unknown 9% in Japan probably because many anesthesia blood levels of histamine and/or tryptase, and a professionals have been convinced of its effec- positive reaction to the culprit drug with skin tiveness. However, in order to use sugamma- 10 Local testing. The authors of this article performed anesthetic dex safely, anesthesia professionals should skin tests on 22 patients with perioperative ana- 9% Sugammadex 32% remain aware of the possibility of anaphylaxis phylaxis at Gunma University Hospital and and observe the patients diligently for at least nearby medical institutions to determine the five minutes after administration. causative agents during the four years from Antibiotics Dr. Takazawa is an Assistant Professor in May 2012 to March 2016. A causative agent for 23% the Intensive Care Unit at the Gunma Univer- the perioperative anaphylaxis was identified in sity Hospital, Gunma, Japan. 20 out of 22 cases. The top three causative Rocuronium agents of perioperative anaphylaxis were Dr. Miyasaka is a Professor in the Department 27% sugammadex in eight patients (32%), of Perianesthesia Nursing at the St. Luke’s Inter- rocuronium in six patients (27%), and antibiotics national University, Tokyo, Japan. in five patients (23%) (Figure 2). The incidence Dr. Sawa is a Professor in the Department of of anaphylaxis due to each drug within our insti- The total percentage exceeds 100%, because a patient Anesthesia at the Teikyo University, Teikyo, tutions is unknown because we did not track with multiple causative agents was included. Japan. the total number of patients who received Dr. Iida is a Professor and Chair in the Depart- those drugs. However, it is true that sugamma- ment of Anesthesiology and Pain Medicine at dex was the most common causative agent of CONCLUSION the Gifu University Graduate School of Medi- perioperative anaphylaxis in our study. We pre- We have presented data that were reported cine, Gifu, Japan. sented these results at the 2016 63rd annual by the PMDA, JSA, and data from Miyazaki et meeting of the JSA in Fukuoka, Japan. In a al., regarding the incidence of sugammadex- All authors are members of the Safety Committee of recently published study of potential sugamma- induced anaphylaxis. Given the variability in the the Japanese Society of Anesthesiologists. The dex-induced anaphylaxis at a single center in reported incidences of sugammadex-induced authors have no further disclosures as they pertain to the present article. Japan by Miyazaki et al., elevated plasma trypt- anaphylaxis between studies, and the lack of a ase levels were observed in only one out of the true denominator containing the number of six patients studied while the diagnosis of REFERENCES sugammadex doses administered, a precise sugammadex-induced anaphylaxis was based 1. Takazawa T, Tomita Y, Yoshida N, et al. Three sus- estimate of the incidence cannot be ascer- pected cases of sugammadex-induced anaphylactic on the timing of the appearance of clinical shock. BMC Anesthesiol 2014;14:92. 7 tained at this time. Since the reports by the symptoms. Although the skin testing is the 2. Godai K, Hasegawa-Moriyama M, Kuniyoshi T, et al. gold standard for identifying the causative PMDA and JSA used a framework in which phy- Three cases of suspected sugammadex-induced hyper- agent of anaphylaxis, it has some disadvan- sicians voluntarily reported cases of anaphy- sensitivity reactions. Br J Anaesth 2012;109:216–8. tages. Skin testing may induce the recurrence laxis, it is unlikely that these reports captured all 3. Obara S, Kurosawa S, Honda J, et al. Cardiac arrest of anaphylaxis, although the possibility is low. In cases of anaphylaxis resulting in underestima- following anaphylaxis induced by sugammadex in a regional hospital. J Clin Anesth 2017;44:62–3. addition, patients can experience pain during tion. In contrast, the study by Miyazaki et al. is 4. Nakanishi T, Ishida K, Utada K, et al. Anaphylaxis to the skin testing. Specific IgE measurement is an limited by small numbers, practice at a single sugammadex diagnosed by skin prick testing using alternative in-vitro method for allergy testing but institution, and insufficient testing. Although both sugammadex and a sugammadex-rocuronium mixture. Anaesth Intensive Care 2016;44:122–4. requires a blood sample, and detection of JSA annually asks member facilities to submit sugammadex-specific IgE has not been 5. Johansson SG, Bieber T, Dahl R, et al. Revised nomen- an incidence report of “accident cases” (cases clature for allergy for global use: Report of the reported. Recently, it has been suggested that where complications occurred but could not be Nomenclature Review Committee of the World the basophil activation test can be used for Allergy Organization, October 2003. J Allergy Clin forseen by anesthesia professionals), the pri- diagnosing sugammadex-induced anaphy- Immunol 2004;113:832–6. mary objective of their report was not to esti- laxis.11 As with anaphylaxis caused by other 6. Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth drugs, performing multiple tests is necessary to mate the incidence of anaphylaxis due to individual drugs. Thus, further studies are 2016;30:290–7. increase accuracy in the diagnosis of sugam- 7. Miyazaki Y, Sunaga H, Kida K, et al. Incidence of ana- madex-induced anaphylaxis. needed to determine the incidence of sugam- phylaxis associated with sugammadex. Anesth Analg 2017; Oct 19. doi: 10.1213/ANE.0000000000002562. [Epub ahead of print] APSF EXECUTIVE COMMITTEE INVITES COLLABORATION 8. Reddy JI, Cooke PJ, van Schalkwyk JM, et al. Anaphy- From time to time, the Anesthesia Patient Safety Foundation reconfirms its commitment laxis is more common with rocuronium and succinyl- choline than with atracurium. Anesthesiology to working with all who devote their energies to making anesthesia as safe as humanly 2015;122:39–45. possible. Thus, the Foundation invites collaboration from all who administer anesthesia, all 9. Tsur A, Kalansky A. Hypersensitivity associated with who provide the settings in which anesthesia is practiced, and all individuals and organiza- sugammadex administration: a systematic review. Anaesthesia 2014;69:1251–7. tions who, through their work, affect the safety of patients receiving anesthesia. The APSF 10. Dewachter P, Mouton-Faivre C, Emala CW. Anaphy- is eager to listen to their suggestions and to work with them toward the common goal of laxis and anesthesia: controversies and new insights. safe anesthesia for every patient. If you are interested, please contact Mark Warner, MD at Anesthesiology 2009;111:1141–50. 11. Takazawa T, Horiuchi T, Yoshida N, et al. Flow cyto- [email protected]. metric investigation of sugammadex-induced ana- phylaxis. Br J Anaesth 2015;114:858–9. APSF NEWSLETTER June 2018 PAGE 13

EDITORIAL: Sugammadex: The Anaphylactic Risk by David Corda, MD, and Nikolaus Gravenstein, MD New substances in our pharmaceutical arma- sugammadex anaphylaxis different from other mentarium occur with reassuring frequency. anaphylactic reactions we see in the operating When they tangibly affect our practice, they can room? Historically, most intraoperative anaphy- be a tremendous clinical adjunct. While some laxis is in response to the administration of an do not withstand the test of time, others do. antibiotic, muscle relaxant, or latex—with the Sugammadex is an example of the latter. It latter in decline as there is much less latex in gained FDA approval and arrived in the United modern operating rooms.4 If one estimates the States (12/2015) much later than in Europe actual anaphylactic rate to sugammadex as (2008) or Japan (2010), where there are now roughly similar to that of rocuronium as refer- many years of patient-accumulated experi- enced by Takazawa et al., then with the increased ences using this drug. In this APSF Newsletter usage of sugammadex, we could estimate that issue, Dr. Takazawa and colleagues nicely detail the total incidence of intraoperative anaphylactic the Japanese experience where it is estimated events will increase by at least one-third. If the that up to 10% of the Japanese population has current rate of intraoperative anaphylaxis is 1:10- already been exposed to sugammadex.1 With 20,000, it might increase to 1:6-14,000.4 any drug, and especially a new one, there is With antibiotics, muscle relaxants, and latex, always an underlying concern of a significant we expect and generally see reactions early in anaphylaxis occurs, it responds to the usual allergic reaction. In point of fact, the FDA an OR case. Unlike these, sugammadex is typi- therapy and that our anecdotal local incidence delayed approval of sugammadex in the United cally administered at the end of a case. Thus a is < 1:4,000, i.e., < 0.025%. States several times largely predicated on con- distinct difference is the timing of the anaphylaxis cerns surrounding hypersensitivity reactions.2 In summary, anaphylaxis to sugammadex is a presentation and vigilance for anaphylaxis that potentially high-consequence event that most Although most sugammadex hypersensitivity may occur at what is historically an unexpected assuredly happens as described by Takazawa reactions cause mild symptoms such as sneez- time for such an event. When sugammadex ana- et al. at some unclear but low frequency. It may ing, nausea, rash, and urticaria, there is a small phylaxis happens, it seems to occur within 5 min- occur without prior intravenous exposure. 5 but finite risk of anaphylaxis with potentially life- utes of administration. Interestingly, the Importantly, anaphylaxis appears more likely at threatening symptoms such as airway edema, likelihood of anaphylaxis with sugammadex higher sugammadex doses, occurs at the end 3 bronchospasm, and cardiovascular collapse. appears to be dose-related. Therefore, it would of case (within five minutes of exposure), and Although the mechanism of sugammadex make sense to use the lowest effective dose to responds to standard epinephrine-based ana- “anaphylaxis” remains unclear, it is encouraging decrease the incidence of anaphylaxis. As an phylaxis treatment. that the risk does not seem to increase with approximate rule of thumb, it requires 4 mg (3.57 Dr. Corda is an Assistant Professor of Anes- repeated exposure, which is often inevitable mg to be exact) sugammadex to encapsulate/ thesiology and Chief of Multispecialty Anesthe- with some patients. Interestingly, the risk of antagonize 1 mg rocuronium; thus a 200-mg sia at the University of Florida. hypersensitivity reactions appears to increase reversal dose is adequate for most cases.6 2 Dr. Gravenstein is The Jerome H. Modell Pro- with higher doses of the drug. Should significant anaphylaxis to sugamma- fessor of Anesthesiology, Professor of Neuro- As Dr. Takazawa et al. point out through their dex occur, the first-line treatment is small surgery, and Professor of Periodontology at the reported experience in Japan, the actual risk of boluses of epinephrine titrated to response, fol- University of Florida. sugammadex-induced anaphylaxis is very diffi- lowed by an epinephrine infusion when 7 cult to determine given the information to date. needed. As an example, a case from our insti- Neither author has any disclosures as they pertain to The authors report an incidence ranging from tution, which was reported to MedWatch, the present article. 0.0025% to 0.039%. This is a 15-fold difference involved an elderly man with previous anaphy- depending on the use of data from the Japa- laxis to a non-steroidal anti-inflammatory drug. REFERENCES 1. Takazawa T, Katsuyuki M, Sawa T, et al. The current status nese FDA equivalent or reporting from a single Rocuronium was reversed at the end of the of sugammadex usage and the occurrence of sugamma- center study. As the authors suggest, much of case with 2 mg/kg sugammadex. One minute dex-induced anaphylaxis in Japan. APSF Newsletter this variability stems from difficulty in recogni- later, the patient’s blood pressure dropped to a 2018;33:1. 2. https://www.accessdata.fda.gov/drugsatfda_docs/ tion, confirmation, and perhaps most impor- systolic blood pressure in the 40s with accom- nda/2015/022225Orig1s000SumR.pdf . Accessed March tantly voluntary reporting. This voluntary panied desaturation, skin flushing, and severe 2018 . reporting (numerator) that we also have in the bronchospasm. The patient was treated with 3. Bridion® Prescribing Information: Accessed on March 29, 2018. https://www.merckconnect.com/bridion/dosing.html- United States makes it difficult to accurately intravenous epinephrine (three 20-mcg ?gclid=CjwKCAjwwPfVBRBiEiwAdkM0HRmYcD7oNbtdcO estimate the incidence (the reported cases of boluses), diphenhydramine (50 mg), dexameth- S7t1oDoUuYjy4YMCBaNzrdE3x3zTCLAboW4mMMwxoCF- anaphylaxis/total number of dose-exposed asone (12 mg) and famotidine (20 mg). The 5cQAvD_BwE&gclsrc=aw.ds. Accessed March 2018 . 4. Mertes PM, Malinowsky JM, Jouffroy L, et al. Reducing the patients). So what do we know? The package patient’s symptoms subsided over 10 minutes, risk of anaphylaxis during anesthesia: 2011 updated insert from Merck and Co. describes an eye- and he was briefly administered a low-dose guidelines for clinical practice. Journal of Investigational brow-raising incidence of 0.3% hypersensitivity epinephrine infusion. His tryptase level after Allergy and Clinical Immunology 2011;21:442. 3 5. Tsur A., Kalansky A. Hypersensitivity associated with reactions in healthy study volunteers. This is the event came back significantly elevated at sugammadex administration: a systematic review. Anaes- many-fold higher than the incidences described 74 ng/mL.8 This was the first sugammadex ana- thesia 2014;69:1251–1257. by Takazawa et al., and similarly far exceeds our phylaxis event in our institution after approxi- 6. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring challenges and opportunities. own anecdotal two-year clinical experience. mately 4,500 patients had been administered Anesthesiology 2017;126:173–190. Ultimately, anaphylaxis is a binary event for the the drug. A second case approximately one 7. McEvoy MD, Thies KC, Einav S, et al. Cardiac arrest in the patient and the provider—either it happens or it year later presented as isolated bronchospasm operating room: part 2—special situations in the perioper- Anesthesia & Analgesia doesn’t. without cardiovascular collapse and was ative period. 2018; 126:889–903. 8. Schwartz L. (2018). Laboratory tests to support the clinical So what lessons might we take from Takazawa resolved with two 20-mcg epinephrine boluses. diagnosis of anaphylaxis. In J.M Kelso (Ed.). Accessed on It is encouraging that case reports and personal March 5, 2018 from https://www.uptodate.com/contents/ et al. about this new drug and the concern for the laboratory-tests-to-support-the-clinical-diagnosis-of-ana- possibility of an anaphylactic response? How is experience confirm that when sugammadex phylaxis?source=see link#H3 APSF NEWSLETTER June 2018 PAGE 14

Can Prescription Drug Monitoring Programs Aid Perioperative Clinicians in Reducing Opioid-Induced Ventilatory Impairment? by David M. Dickerson, MD

More than 1.9 million Americans are esti- discussed.4 Identifying patient risk factors can quent catastrophic injury.13 Research validating mated to have a prescription opioid use disor- be challenging, but there is a tool available to the Risk Index for Overdose or Serious Opioid- der.1 A diagnosis of opioid use disorder is help anesthesia professionals and other periop- Induced Respiratory Depression (RIOSORD) based on evidence of impaired control in erative clinicians identify patients with prior and suggests that opioid-tolerant patients are at sig- avoiding use, social impairment, risky use, current opioid use—prescription drug monitor- nificant risk for OIVI relative to patients without a spending a significant time obtaining and using ing programs (PDMPs). This article reviews the history of opioid prescriptions and/or opioid tol- opioids, diminishing returns or tolerance to opi- relationship of prior opioid use to OIVI (includ- erance.14,15 For example, a patient taking short- oids and withdrawal symptoms that occur after ing the concept of differential tolerance) and acting morphine in excess of 100-mg morphine 1 stopping or reducing use. Treatment for opioid discusses how perioperative clinicians may uti- equivalents per day would score 18 points on the use disorder with bupenorphine therapy lize PDMPs to better identify patients in whom 146-point RIOSORD scale, corresponding to a 2 increased by 52% from 2012 to 2016. The opioid tolerance may contribute to risk for OIVI. 29.8% probability of OIVI. If that same patient misuse of opioids contributes to tens of thou- NATIONAL TRENDS IN OPIOID were to also have a substance use disorder sands of deaths each year; in 2016 overdose PRESCRIPTION AND OPIOID ABUSE (abuse or dependence), this risk jumps to deaths associated with opioids surpassed 15 1,3 The acute rise in medical opioid prescriptions 83.4%. Table 1 details the patient factors that death from motor vehicle crashes. In the over the past two decades has driven an increas- contribute to the RIOSORD. Over the past February 2018 issue of the APSF Newsletter, ing prevalence of potentially opioid-tolerant and decade, treatment for opioid misuse has patient- and practice-based risk factors for opi- opioid-dependent individuals presenting for pro- increased, as have opioid prescribing rates.5 oid-induced ventilatory impairment (OIVI) were 3,5 cedural care. Over the past ten years, there are Given the risk for OIVI in this population, height- mixed data regarding trends in prescription ened provider awareness is paramount. Table 1: Factors* included in Risk Index opioid use. National opioid prescription rates for Overdose or Serious Opioid-Induced peaked in 2012, and there has been a slight RELEVANCE OF PREOPERATIVE OPIOID 15 Respiratory Depression (RIOSORD) decrease in the number of prescriptions and pre- USE TO OIVI scribed dosages since then. However, data show A recent review estimates that the incidence Has the patient received care for any of that prescribed duration of therapy slightly of postoperative OIVI is approximately 0.5%.16 the following health conditions in the past increased from 2006 to 2016; the percentage of In one study included in this review, opioid 6 months? opioid prescriptions for a greater than 30-day dependence or abuse contributes to OIVI with • Substance use disorder (abuse or supply increased from 17.6% to 27.3% from 2006 an odds ratio of 3.1 (95% CI:2.7-3.6), and previ- dependence) (includes alcohol, cannabis, to 2016.5 From 2013 to the present, the percent- ous substance abuse and chronic pain strongly cocaine, hallucinogens, opioids, and age of prescriptions for >30-day supply has predict opioid overdose.17,18 Preadmission sub- sedatives/anxiolytics decreased slightly, but not enough to offset the stance abuse history, opioid exposure, and • Bipolar disorder or schizophrenia net 9% increase since 2006.5 • benzodiazepine exposure are major predictors Stroke or other cerebrovascular disease 14,15 • Kidney disease with clinically significant PREVALENCE OF PREOPERATIVE in the aforementioned RIOSORD. While renal impairment OPIOID USE these retrospective studies are compelling, pro- • Heart failure Rates of preoperative opioid use vary across spective studies are still needed to adequately • Nonmalignant pancreatic disease surgical populations and are higher than in the characterize risk factors for OIVI. • Chronic pulmonary disease general public. In Canada, 18.5% of patients DIFFERENTIAL TOLERANCE: • Recurrent headache presenting for ambulatory surgery were taking 6 A POTENTIAL MECHANISM FOR OIVI IN Does the patient consume any of the opioids preoperatively. A U.S. study of patients THIS POPULATION undergoing spinal fusion had significant vari- following? It may be counterintuitive that opioid toler- ability in the use of preoperative chronic opioid • Fentanyl† ance is associated with a higher risk of OIVI. therapy, with the majority (71.7%, 1,787/2,491) • Morphine† However, tolerance of opioid-induced analge- † using some preoperative opioids (58.5% with • Methadone sia does not correlate with tolerance to OIVI.19,20 • Hydromorphone† long-term, 24.5% with episodic use, 5.3% with short-term use).7 These studies suggest geo- This may be related, in partto the finding that • Extended release or long-acting opioid-dependent patients may exhibit formulation of any prescription opioid† graphic and procedure-related variation as well impaired hypercapnic ventilatory response • A benzodiazepine† as methodological variation in defining chronic 7,8 even in the absence of acute opioid exposure.21 • An antidepressant exposure. Continued opioid administration or dose esca- Does the patient currently consume a pre- PERIOPERATIVE MANAGEMENT lation potentiates opioid-induced respiratory scribed opioid dose greater than or equal OF THE OPIOID-TOLERANT PATIENT depression and sedation and may reflect dif- to 100 mg morphine equivalents per day Preoperative opioid use and pain create sig- ferential tolerance.16 In closed-claims analysis, nificant challenges for the perioperative clinician. on a regular basis?† sedation was identified as a preceding symp- Preoperative opioid use predicts uncontrolled tom of OIVI in 62% of the events.4 Animal stud- *Each factor is associated with a different number of pain, increased costs, and poor satisfaction after ies demonstrate differential tolerance develops points or risk contribution in the RIOSORD. orthopedic and general surgery.9-12 Retrospec- † within a matter of hours of initial opioid expo- Reported in prescription drug monitoring programs. tive studies suggest a correlation between RIOSORD was validated in both Veterans Health chronic or preexisting opioid use with an sure suggesting a potential issue for opioid- 14 15 22 Administration (VHA) and non-VHA populations. increased likelihood of in-hospital respiratory naïve individuals. This table uses risk factors from the non-VHA validation study. depression requiring intervention and subse- See “Monitoring Programs,” Next Page APSF NEWSLETTER June 2018 PAGE 15

Prescription Drug Monitoring Programs May Help Guide Clinicians in Developing a Perioperative Pain Care Plan

From “Monitoring Programs,” Preceding Page care scenarios did not create incremental reduc- filled but did not take a prescription. Such tion when combined with registration mandates instances can provide valuable and relevant Lee et al. discuss the potential challenges of or implemented independently.25 This suggests information such as potential side effects, intol- implementing a comprehensive OIVI risk factor provider awareness of PDMPs via registration erance, or inefficacy when exposed to that checklist.4 Still, a standardized approach for enables appropriate prescribing and suggests medication previously reflecting occult pharma- identifying key patient factors, such as preopera- that use mandates may have too narrow of a cogenomic issues or potential safety issues. tive opioid use, may be useful in developing scope to impact measurable changes in pre- analgesic strategies that account for differential Finally, partial opioid receptor agonist/antago- scribing data.25 risk of OIVI. One such approach is PDMPs, which nists such as buprenorphine also appear in the may aid clinicians in identifying those patients The clinical utility and impact of PDMP review PDMP. Identifying use of these agents facilitates who either have previously used or are actively by perioperative clinicians, however, is unknown broadened treatment planning and possible using opioids or benzodiazepines (another RIO- and is a topic for future study. High-value utiliza- case deferral for possible cessation of such ther- SORD risk factor14), and who may be subse- tion requires awareness of the PDMPs exis- apy prior to more painful surgery. Importantly, the quently at higher risk for perioperative OIVI. tence and capabilities, the current national presence of such medication suggests potential trends in opioid use and misuse, and the clinical ongoing medication-assisted treatment for PRESCRIPTION DRUG MONITORING relevance of ongoing opioid use and addiction addiction, a comorbidity known to increase the PROGRAMS (PDMPS) as factors in perioperative outcomes. risk of in-hospital respiratory failure.14 PDMPs are state-administered monitoring THE PDMP: A VALUABLE TOOL While far from a standard of care, the supple- programs that detail pharmacy-dispensed con- FOR PERIOPERATIVE CARE? mentary information offered by PDMPs may trolled substances shortly after the medication When the state of Illinois amended its con- improve the quality of care provided to patients is released to the patient. Currently enacted in trolled substance act requiring all clinicians to with preoperative opioid use, tolerance, or all 50 states, PDMPs (also called prescription register to use the PDMP, relevance for many misuse. Moving forward, integration of PDMP monitoring programs—PMPs) provide a mecha- anesthesia professionals and intensivists was data into electronic health records in a dynamic nism for identifying preoperative opioid and unclear, because both groups rarely prescribe fashion (as opposed to the “flat” or read-only benzodiazepine use. Aberrant behaviors such post-hospital opioids. However, there are sev- formatting most in use today) will enable the use as frequent opioid prescriptions from multiple eral reasons that PDMPs may be useful to peri- of clinical decision support tools that may help in prescribers suggest prescription misuse or operative clinicians. further mitigating risk of OIVI and improve anal- overuse, and these patterns would be identifi- gesia for opioid-tolerant patients. able from PDMP records. Methadone dis- First, PDMPs can be used to evaluate a pensed by methadone clinics represents a patient’s preoperative or preadmission opioid CONCLUSION blind spot, as it does not typically appear in exposure and potential for tolerance, misuse, or Prescription drug monitoring programs may PDMPs, but several states have proposed such dependence. Preoperative clinics could use the offer a novel, supplementary data source for inclusion to their state legislatures. Another PDMP to identify and guide candidates for pre- gathering important patient information for peri- reported pending addition to state-run PDMPs operative opioid weaning or increased monitor- operative treatment planning and risk stratifica- is the inclusion of Emergency Medical Services ing on the day of surgery. PDMPs also facilitate tion. The multidisciplinary discussion of PDMP administration of naloxone. gathering information that may be unobtainable data preoperatively can guide preoperative due to the emergent or urgent nature of pre- patient preparation and education, periopera- Despite being run by states, there is a mech- sentation, as in a trauma setting. anism for sharing information across PDMPs. tive pain care, postoperative and postdischarge The PMP InterConnect® program of the National Second, they may help in the creation of monitoring and patient follow-up. The value of Association of Boards of Pharmacy (NABP) analgesic regimens for opioid-tolerant patients, such utilization relies on provider recognition of who are at risk for severe, uncontrolled, and enables the 45 enrolled states to view prescrib- the prevalence and significance of preopera- persistent pain. While recommended by multi- ing data of the other NABP participant states.23 tive opioid use and misuse and the specific society postoperative pain guidelines, compre- This InterConnect® system may allow for regula- relationship between these factors and periop- hensive preoperative evaluation of patient’s erative outcomes. tory bodies and clinicians to identify those pain or psychiatric history varies substantially in patients seeking care from multiple providers in Dr. Dickerson is Director of the Acute Pain Ser- practice,26 and PDMP review could constitute states with separate PDMPs. vice and Assistant Professor in the Department part of this history taking. Recognizing a pattern of Anesthesia & Critical Care at the University of THE IMPACT OF PDMPS of frequent prescriptions from multiple provid- Chicago. ON OPIOID PRESCRIBING ers or longstanding benzodiazepine prescrip- PDMPs may reduce opioid overdose deaths tions may suggest potential complexity in pain Dr. Dickerson has no financial disclosures. and curb opioid prescribing rates via heightened management,11,15,18 and might inform clinicians clinician awareness of high-risk use including about the appropriate analgesic choices or the REFERENCES misuse or diversion. For instance, Florida saw a decision to obtain an early acute pain service 1. Han B, Compton W, Blanco W, et al. Prescription consultation. Additionally, patients may not opioid use, misuse, and use disorders in U.S. adults: 25% reduction in oxycodone-caused mortality 2015 national survey on drug use and health. Ann Int after PDMP implementation and other states always be forthcoming due to fear of stigma, Med 2017;167:293-301. have seen similar trends.24 Registration and use fear of legal consequences, or other concerns. 2. IMS Institute for Healthcare Informatics. Use of opioid mandates as well as use exemptions are state- PDMPs, while not comprehensive, provide recovery medications: recent evidence on state level information that may not be disclosed. buprenorphine use and payment types. 2016. https:// specific. Mandating health care professionals www.iqvia.com/-/media/iqvia/pdfs/institute-reports/ register for PDMP use significantly reduced Third, discussion with patients of prescription use-of-opioid-recovery-medications.pdf. Accessed opioid prescribing rates in adopting states, yet data found in the PDMP may identify potential 4/1/2018. mandating clinicians use the PDMP for specific discrepancies or instances in which patients See “Monitoring Programs,” Next Page APSF NEWSLETTER June 2018 PAGE 16

The Potential Value of Prescription Drug Monitoring Programs Get Social With Us! From “Monitoring Programs,” Preceding Page 15. Zedler BK, Saunders WB, Joyce AR, et al. Validation of a screening risk index for serious prescription opioid- 3. Center for Behavioral Health Statistics and Quality. induced respiratory depression or overdose in a US Behavioral health trends in the United States: Results Commercial Health Plan Claims Database. Pain Medi- from the 2014 National Survey on Drug Use and cine 2018;19:68–78. Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). 2015. https://www.samhsa.gov/data/ 16. Gupta K, Prasad A, Nagappa M, et al. Risk factors for opi- sites/default/files/NSDUH-FRR1-2014/NSDUH- oid-induced respiratory depression and failure to rescue: FRR1-2014.pdf. Accessed 4/1/2018. a review. Curr Opin Anaesthesiol 2018;31:110–119. 4. Lee L, Posner K, Domino K. We should focus on 17. Menendez ME, Ring D, Bateman BT. Preoperative “when” as well as “whom” to monitor for postopera- opioid misuse is associated with increased morbidity tive opioid-induced ventilator impairment. APSF and mortality after elective orthopaedic surgery. Clin Newsletter 2018:32:59–60. Orthop Relat Res 2015;473:2402–2412. 5. Centers for Disease Control and Prevention. Annual 18. Cauley CE, Anderson G, Haynes AB, et al. Predictors surveillance report of drug-related risks and out- comes—United States, 2017. Surveillance Special of in-hospital postoperative opioid overdose after Report 1. 2017. https://www.cdc.gov/drugoverdose/ major elective operations: a nationally representative pdf/pubs/2017cdc-drug-surveillance-report.pdf. cohort study. Ann Surg 2017;265:702–708. Marjorie Stiegler, MD, APSF Director of Digital Strategy and Social Media Accessed 4/1/2017. 19. Hayhurst CJ, Durieux ME. Differential opioid tolerance 6. Wilson JL, Poulin PA, Sikorski R, et al. Opioid use and opioid-induced hyperalgesia: a clinical reality. among same-day surgery patients: prevalence, man- Anesthesiology 2016;124:483–488. The APSF is eager to connect with patient agement and outcomes. Pain Res Manag 20. Athanasos P, Smith CS, White JM, et al. Methadone safety enthusiasts across the internet on 2015;20:300–304. maintenance patients are cross-tolerant to the antino- our social media platforms. Over the past 7. Deyo RA, Hallvik SE, Hildebran C, et al. Use of pre- ciceptive effects of very high plasma morphine con- scription opioids before and after an operation for year, we have made a concerted effort to centrations. Pain 2006;120:267–275. chronic pain (Lumbar Fusion Surgery). Pain 2018. Pub- grow our audience and identify the best lish Ahead of Print: MAR 2018 DOI: 10.1097/j. 21. Teichtahl H, Wang D, Cunnington D, et al. Ventilatory content for our community. Starting from pain.0000000000001202 responses to hypoxia and hypercapnia in stable scratch, we’ve seen increases in followers 8. Jain N, Phillips FM, Weaver T, et al. Preoperative methadone maintenance treatment patients. Chest chronic opioid therapy: a risk factor for complications, 2005;128:1339–1347. and engagement by several thousand per- readmission, continued opioid use and increased 22. Ling GS, Paul D, Simantov R, et al. Differential devel- cent, and we hope to see that trajectory costs after one- and two-level posterior lumbar fusion. opment of acute tolerance to analgesia, respiratory continue into 2018. Please follow us on Spine (Phila Pa 1976). 2018 Mar 20. doi: 10.1097/ depression, gastrointestinal transit and hormone BRS.0000000000002609. [Epub ahead of print]. Facebook at www.facebook.com/APSForg release in a morphine infusion model. Life Sci 1989; 9. Zywiel MG, Stroh DA, Lee SY, et al. Chronic opioid use 45:1627–36. and on Twitter at www.twitter.com/APS- prior to total knee arthroplasty. J Bone Joint Surg Am Forg. Also, connect with us on Linked In at 2011;93:1988–1993. 23. NABP PMP InterConnect: The Only National Network of State-Based PMPs. https://nabp.pharmacy/initia- www.linkedin.com/company/anesthesia- 10. Cron DC, Englesbe MJ, Bolton CJ, et al. Preoperative opioid use is independently associated with tives/pmp-interconnect/. Accessed 4/4/2018. patient-safety-foundation-apsf. We want to increased costs and worse outcomes after major 24. Delcher C, Wagenaar AC, Goldberger BA, et al. hear from you, so please tag us to share abdominal surgery. Ann Surg 2017;265:695–701. Abrupt decline in oxycodone-caused mortality after your patient safety related work, including 11. Ip HY, Abrishami A, Peng PW, et al. Predictors of post- implementation of Florida’s Prescription Drug Moni- your academic articles and presentations. operative pain and analgesic consumption: a qualita- toring Program. Drug Alcohol Depend 2015;150:63– tive systematic review. Anesthesiology 2009;111: 68. We’ll share those highlights with our com- 657–677. 25. Wen H, Schackman BR, Aden B, et al. States with pre- munity. If you are interested in joining our 12. Schwenkglenks M, Gerbershagen HJ, Taylor RS, et al. scription drug monitoring mandates saw a reduction efforts to amplify the reach of APSF across Correlates of satisfaction with pain treatment in the in opioids prescribed to medicaid enrollees. Health acute postoperative period: results from the interna- the internet by becoming an Ambassador, Aff(Millwood). 2017;36:733–741. tional PAIN OUT registry. Pain 2014;155:1401–1411. please reach out via email to Marjorie 13. Lee LA, Caplan RA, Stephens LS, et al. Postoperative 26. Chou R, Gordon DB, de Leon-Casasola OA, et al. Stiegler, MD, our Director of Digital Strat- opioid-induced respiratory depression: a closed Management of Postoperative Pain: A Clinical Prac- egy and Social Media at [email protected] claims analysis. Anesthesiology 2015;122:659–665. tice Guideline From the American Pain Society, the or to Emily Methangkool, MD, the APSF 14. Zedler B, Xie L, Wang L, et al. Development of a risk American Society of Regional Anesthesia and Pain index for serious prescription opioid-induced respira- Medicine, and the American Society of Anesthesiolo- Ambassador Program Director at Meth- tory depression or overdose in veterans’ health gists’ Committee on Regional Anesthesia, Executive [email protected]. We look forward to administration patients. Pain Medicine 2015;16:1566– Committee, and Administrative Council. The Journal seeing you online! 1579. of Pain 2016;17:131–157.

Support Your APSF —Your Voice in Patient Safety— Please donate online at apsf.org or make checks payable to the APSF and mail donations to Anesthesia Patient Safety Foundation (APSF) Charlton 1-145, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, U.S.A. APSF NEWSLETTER June 2018 PAGE 17

Safe Gas Systems and Office-Based Anesthesia by Jonathan L. Wong, DMD, and Gerhard Gschwandtner, PEng

CURRENT TRENDS IN OUTPATIENT ANESTHESIA Outpatient sedation and anesthesia is noth- ing new. Ambulatory surgical centers are com- monplace and widely accepted as a safe, convenient, and cost-effective means of deliv- ering surgical care. Off-site anesthesia in loca- tions remote to the operating room is also becoming increasingly prevalent. Office-based anesthesia (Figure 1) qualifies as a remote loca- tion and continues to grow in obstetrics and gynecology, plastic surgery, fertility clinics, oph- thalmology, gastroenterology, and dentistry. Dentists pioneered many of the techniques of anesthesia in an outpatient setting and were at the forefront of office-based anesthesia as well. So why are dental offices under such criticism? One major reason is that many dentists and oral surgeons continue to practice as operator anes- thetists without adequate training of their support personnel and a lack of appropriate equipment. Figure 1: Outpatient office where anesthesia can be delivered. This was the basis of the unfortunate circum- NFPA AND NFPA 99 NFPA 99 is the Healthcare Facilities Code. It stances in California that led to the proposal of The National Fire Protection Association is updated every three years. NFPA 99 is the Caleb’s Law after six-year-old Caleb Sears died national code (American National Standards during anesthesia administered by his oral sur- (NFPA) is a global nonprofit organization, estab- lished in 1896, devoted to eliminating death, Institute or ANSI) for all medical and dental gas geon. However, several of the recent public installations in the United States. It is also injury, and property and economic loss due to tragedies in dental offices have involved sepa- adopted by reference in the International fire, electrical, and related hazards. It is widely rate anesthesia professionals. These clinicians Plumbing Code and International Fire Code, known as a codes and standards organization include physician anesthesiologists, certified which are the basis for a majority of state and registered nurse anesthetists (CRNAs), and den- that continually updates codes on a three- to local building codes (these vary by locality). tist anesthesiologists. One of the possible five-year cycle in a process that is open and Many anesthesiologists, nurse anesthe- causes of morbidity and mortality is the lack of consensus-based. Technical committee mem- tists, oral and maxillofacial surgeons, and safety checks in dental offices. One such safety bers are typically volunteers. As Mr. Rusty dentists mistakenly believe that the NFPA 99 check that is almost entirely overlooked is that Chase, a fire marshal, certified fire inspector, of the medical gas system. is merely about fire safety. This is a miscon- and paramedic, stated, “Many code items are ception. NFPA is actually about patient safety developed to address issues that have severely and prevention of medical gas mistakes. injured or killed people in the past (personal communication)." See “Safe Gas Systems,” Next Page

the Anesthesia Patient Safety Foundation find us at: www.apsf.org

THE NEW WEBSITE INCLUDES: ANNOUNCES THE LAUNCH OF THE • Modern dynamic NEWLY DESIGNED accessibility APSF WEBSITE • Newsletter page with new: • Search function • Mobile & Desktop functionality • Website section updates • APSF Board members & Bios • Donations page • Patient Safety Initiatives • Dynamic integration with Figure 2: Zone Valve Box: A – 3 piece full port shut-off social media valve, B – Zone Valve Assembly label, C – Patient side vacuum/pressure indicator gauge. APSF NEWSLETTER June 2018 PAGE 18

Dental Offices Are Not Exempt From Following NFPA 99 From “Safe Gas Systems,” Preceding Page Table 1: NFPA 99 Categories of Medical/Dental Gas Systems

NFPA 99 contains the minimum requirements NFPA 99 2018 Edition for piped gas systems, equipment, materials, alarms, installations, testing, verification, and Category Type Category 3 Category 2 Category 1 maintenance. The requirement applies to all Permissable Depth of Nitrous anxiolysis and Moderate sedation Deep sedation and health care facilities in the U.S., including hos- Anesthesiaa minimal sedation general anesthesia pitals, outpatient facilities, clinics, medical Zone Valvesb Required No Yes Yes offices, and dental offices. Since at least 1996, Zone Alarms Required No Yes Yes NFPA code has required dental offices provid- c d ing sedation and anesthesia to be compliant Master Alarm Panel Yes Single Dual with these minimum standards. Controls for Line Per manufacturer Maintain stable Maintain stable Pressure pressure and flow for pressure and flow for NFPA 99 defines 3 categories (previously peak demand peak demand called levels) of medical and dental gas sys- Vacuum System Dental vacuum Simplexe Duplex,d,e separate tems (Table 1). These categories define the spe- from dental vacuum cific minimum requirements for each system. Waste Anesthetic Gas None Nitrous scavenging Separate Waste The assessment of which category a facility or Scavenging may run through dental Anesthesitic Gas dental office falls under is based on a risk vacuum system Disposal (WAGD) and assessment and not by facility type or occu- medical vacuum from dental vacuum pancy permit. NFPA has assigned certain depths of anesthesia and sedation to each of its Testing and In dental offices using American Society of American Society of three categories. The NFPA adopts the defini- Verification dental gas systems, Sanitary Engineers Sanitary Engineers follow local code and (ASSE) 6030 3rd Party (ASSE) 6030 3rd Party tions of minimal, moderate, and deep sedation manufacturer specs Verifier Verifier and general anesthesia from the American Installation Brazed, soldered, or Brazed with nitrogen Brazed with nitrogen Society of Anesthesiologists’ “Continuum of fitted joints purge purge Depth of Sedation” Guideline.1 In addition, the Reserve Gas Supply Minimum not required One-day reserve One-day reserve above definitions were reiterated and both supply supply minimal and moderate sedation further described in the latest Practice Guidelines for a NFPA adopts the definitions for sedation and anesthesia from the American Society of Anesthesiologists’ “Continuum of Depth of Sedation” verbatim 2 Moderate Procedural Sedation and Analgesia. b Zone Valves are mechanical shut offs for medical gas and vacuum supply lines to each anesthetizing location and each supplied zone such as the PACU. Per NFPA, pressures must be monitored downstream of the valve for each These designations also do not change even gas and upstream for each vacuum supply line (Figure 2). if such services are only offered on a nonrou- c Limited, need not provide real time pressures, only low supply pressure tine basis. The designations do not change d 2018 NFPA 99 Chapter 15 allows a simplex system in a dental office even if fewer than four individuals could be e Simplex refers to a vacuum system that may have multiple vacuum sources, but cannot generate 100% of the demand independently, and therefore is not redundant. A duplex system has 100% redundancy and can operate at incapacitated at the same time. There is a pop- capacity with a single source failure. ular misconception that dental offices do not need to comply with NFPA 99. This misconcep- that anesthesia professionals may mistakenly an associated certification when compared to tion may stem from the NFPA 101 Life Safety assume that dental (Category 3) systems are the ASSE 6010) prior to use. the same as other medical gas systems that are Code, which relates to occupancy and applies Additional patient and staff safety concerns familiar to them. This is, in part, due to the fact when four or more individuals could be inca- arise from the dental air compressors and that Category 3 systems are not routinely dis- pacitated (under or recovering from sedation/ dental vacuum systems. Dental air compres- cussed in texts or training programs,3 as these anesthesia) at the same time; an office is not sors are designed simply for driving dental sur- nitrous dental gas systems were not intended exempt from following the NFPA 99 guidelines. gical instruments. It is highly unlikely that these for sedation and/or general anesthesia. Both systems could be mistaken for medical air, and ANESTHESIA PROFESSIONALS dental and medical gas systems must be thus will not be discussed further. However, AND MEDICAL GAS SYSTEMS installed by an American Society of Sanitary dental vacuum pumps are designed to operate Anesthesia professionals are primarily Engineers (ASSE) 6010 Certified Medical Gas “wet” and do not have a collection canister to trained in the operating room. Training also Installer, as there are strict rules for brazing and prevent contamination of the vacuum line. occurs in hospitals and ambulatory surgery testing these piped systems. Plumbers that are Instead, dental suctions have a “trap” built into centers. These facilities, even at remote sites, not certified medical gas installers mistakenly must comply with NFPA 99 standards. As pro- install some of these systems. This has resulted the dental delivery unit to prevent large debris fessionals, we are not trained to deal with the in medical gas line cross-overs that have from entering the “wet” system. In the event of technicalities of these medical gas systems. resulted in several deaths in dental offices due regurgitation, this system clogs with debris and The authority having jurisdiction (AHJ) is often to hypoxic gas mixtures being delivered to will immediately fail. These vacuum pumps are the fire marshal who is not always aware of the patients. For this reason, all systems except designed to operate at high flow but low level of anesthesia to be provided in an office. dental Category 3 systems, even when installed vacuum. For example, most dental vacuums This is especially true of dental offices, in which by an ASSE 6010 Certified Medical Gas Installer, operate at 10-13 inches of mercury, whereas a it is often assumed that the office will be using must then also be independently tested and medical vacuum is required to maintain a mini- just nitrous oxide and a dental air system (Cate- verified by an ASSE 6030 Medical Gas Verifier mum of 19 inches of mercury. gory 3). Compounding this problem is the fact (who has an additional two years of training with See “Safe Gas Systems,” Next Page APSF NEWSLETTER June 2018 PAGE 19

Routine Maintenance/Certification of Office-Based Gas Systems is Recommended

From “Safe Gas Systems,” Preceding Page NFPA 99 AND ANESTHESIA independent ASSE 6030 medical gas verifier The variability in fresh gas and vacuum flows IN DENTAL PRACTICES has evaluated the medical gas system for any New dental offices should be aware of these may also be a patient safety issue. The variabil- new installation or repair and whenever adding new standards. The major dental equipment ity is due to the lack of compliant source sys- additional sedation or anesthesia services to suppliers often offer design services, but are any office or facility. Although not required by tems and engineering of the gas plumbing. not well versed in medical gas systems. Local Connecting anesthesia machines, through the the NFPA, routine maintenance and certifica- building inspectors often do not inspect dental tion of the gas system is also recommended, use of both gas supply and vacuum fittings and offices for compliance unless the office specifi- just as it is for anesthesia machines. adaptors that allow connection to a Category 3 cally states that they offer certain sedation and system could potentially cause fluctuations in anesthesia services. Professional engineers Dr. Wong is a dentist anesthesiologist in pri- the fresh gas and vacuum flows to the machine. may be needed to design the gas system and vate practice at Coastal Pediatric Dental & The change in vacuum flow could potentially mechanical closet. The thorough testing of Anesthesia in Norfolk, VA. medical gas systems is imperative as it ensures cause increases in positive end expiratory pres- Gerhard Gschwandtner is a professional proper functionality of gas manifolds, alarms, sure (PEEP) as vacuum levels decrease with engineer, certified health care safety profes- and automated switchover valves and ensures concomitant use of the dental vacuum. Inappro- sional, and credentialed medical gas verifier at against system leaks and medical gas line priate fresh gas piping sizes could lead to inad- crossovers. This testing ensures that the medi- Comprehensive, Inc in Cary, NC. equate flows, especially when using the oxygen cal gas system is performing properly much like flush valve. These technical issues rarely cross Both authors have no disclosures relevant to the a biomedical technician certifies the working content of this article. the mind of anesthesia professionals, as they order of anesthesia machines. The redundancy are accustomed to appropriately designed sys- of these systems allows for additional patient Special acknowledgment to Dr. Jan Ehrenw- tems in the hospital. safety and verification. For example, the erth for serving as guest editor. Dr. Ehrenwerth requirement8 during general anesthesia for an presently serves on the APSF editorial board. NFPA 2018 EDITION in-line oxygen analyzer on anesthesia machines The NFPA released the NFPA 99 Healthcare serves as a protection against delivery of a REFERENCES Facilities Code 2018 Edition in November of hypoxic gas mixture in the event of a gas line 1. Continuum of depth of sedation: definition of general 2017. The NFPA worked with the American crossover. The American Dental Association’s anesthesia and levels of sedation/analgesia. Ameri- Dental Association and dental specialty groups Guidelines for the Use of Sedation and General can Society of Anesthesiologists Committee of Qual- ity Management and Departmental Administration; to develop the latest edition. The lack of knowl- Anesthesia by Dentists also requires either an in-line oxygen analyzer or “a functioning device 2014;p. 1–2. edge and adoption of code standards in den- that prohibits the delivery of less than 30% 2. Practice guidelines for moderate procedural sedation tistry was recognized by the NFPA. For oxygen.”9 Of course, these devices may only be and analgesia 2018: A report by the American Society example, The American Academy of Oral and of Anesthesiologists Task Force on Moderate Proce- relied upon with adequate verification of the dural Sedation and Analgesia, the American Associa- Maxillofacial Surgeons (AAOMS) requires that medical gas system installation, which is tion of Oral and Maxillofacial Surgeons, American all "AAOMS fellow/members must have their required by NFPA 99. College of Radiology, American Dental Association, offices successfully evaluated and re-evalu- American Society of Dentist Anesthesiologists, and ated by their component society every five CONCLUSION Society of Interventional Radiology. Anesthesiology 2018;128:437–79. Existing offices should understand the regu- years or in accordance with the state law, pro- 3, Malayaman SN, Mychaskiw G, Ehrenwerth J; Medical vided that the state law does not exceed six latory issues included in NFPA 99 and the rele- gases: storage and supply, Chapter 1 in Ehrenwerth J, years between evaluations and otherwise vant society guidelines when introducing new Eisenkraft J, and Berry J: Anesthesia equipment: prin- sedation and anesthesia services. An existing meets AAOMS office anesthesia guidelines.”4 ciples and applications. Second Edition. Elsevier, Category 3 medical gas system is not permissi- Philadelphia, 2013. However, AAOMS Parameters of Care5 are ble when adding sedation and anesthesia ser- 4. Office-Based anesthesia provided by the oral and silent on NFPA 99 adherence. Individual state vices, just because the system is already maxillofacial surgeon: White Paper. American Asso- dental board requirements are also highly vari- present at the dental office. This also applies ciation of Oral and Maxillofcial Surgeons; 2016; p. 3. able and do not discuss NFPA 99 require- when independent anesthesia professionals 5. Anesthesia in outpatient facilities. Parameters of care: ments. Therefore, NFPA 99 has explicitly clinical practice guidelines for oral and maxillofacial are brought into the office to assist in treatment surgery (AAOMS ParCare 2012). 5th ed. Rosemont, IL: included dental offices in Chapter 15 “Dental of patients. In addition, offices providing seda- American Association of Oral and Maxillofacial Sur- Gas and Vacuum Systems.”6 The NFPA tion and anesthesia without the proper inde- geons; 2012;e31–e49. decided to explicitly include dental facilities in pendent third-party certification of their gas 6. NFPA 99: Health Care Facilities Code, 2018 ed. their own chapter to address the issues dis- system, may, at the very least, be responsible Boston, MA: National Fire Protection Association; 2017. cussed above. However, they did not “grandfa- for notifying the authority having jurisdiction of such. As one state-level AHJ and professional 7 NFPA 99: Health Care Facilities Code, 2018 ed. ther” in existing systems in dental offices. engineer stated, “This, however, does not Boston, MA: National Fire Protection Association; Instead, NFPA 15.1.5 states, “An existing system 2017; Section 15.1.5, p. 122. relieve the building owners, contractors, archi- that is not in strict compliance with the require- tects, engineers, material suppliers, and anyone 8 Standards for basic anesthetic monitoring. American ments of this code shall be permitted to con- Society of Anesthesiologists Committee of Standards involved including the dental practitioners in and Practice Parameters; 2015, p. 2. tinue in use as long as the authority having the construction of the medical gas systems 9 Guidelines for the use of sedation and general anes- jurisdiction has determined that such use does from complying to this code (personal commu- thesia by dentists. Chicago, IL: American Dental Asso- not constitute a distinct hazard to life.”7 nication).” The best practice is to ensure that an ciation; 2016; p. 10 & 13. APSF NEWSLETTER June 2018 PAGE 20 Dear SIRS: SAFETY INFORMATION RESPONSE SYSTEM

"No Read" Errors Related to Prefilled Syringes

Dear SIRS: consequences, but became apneic and was present issue, our pharmacy placed a paper paralyzed without anesthesia. Following a label on the succinylcholine syringes. How- Prefilled syringes provide considerable department-wide Morbidity and Mortality con- ever, this negates the purpose of purchasing benefit to anesthesia professionals including ference shortly after this event, another patient sterility, convenience, affordability, and per- prefilled and pre-labeled syringes. In addi- was accidentally administered IV 480 mcg (6 ceived safety.1 At our institution, we use tion, it may create new threats of drug error syringes from multiple manufacturers and ml) phenylephrine after induction of anesthesia and associated morbidity. instead of 120 mg (6 ml) succinylcholine. No- have realized several of the benefits above. The authors partnered with the APSF and read errors are primarily the responsibility of the Here, however, we report a pair of “no-read” Nephron Pharmaceuticals, who efficiently care provider team. However, we determined medication administration errors related to acknowledged the problem and created prefilled syringes of phenylephrine and suc- that the specific packaging of the syringes and new labels (see Figures 2a and 2b) that we cinylcholine manufactured by Nephron Phar- the associated potentially dangerous visual believe will help prevent this pattern of drug maceuticals Corporation (Columbia, SC). The similarity of the specific products may also con- administration errors. We appreciate the first event involved a patient accidentally tribute to the drug error (Figures 1a and 1b). The receiving 40 mg of intravenous (IV) succinyl- present syringes meet the ASTM standards, but support and ethos that APSF provided to choline for hypotension during the process the lack of circumferential red color around the our concern and the responsiveness by of moving to the operating room table. The succinylcholine syringe may lead to accidental Nephron Pharmaceuticals. patient suffered no apparent long-term administration of a paralytic.2 To address this See “Dear SIRS,” Next Page

1a 2a

1b 2b

Figure 1a: Front, 1b: Reverse: original syringes of phenylephrine (top) and succinyl- Figure 2a: Front, 2b: Reverse: redesigned syringes with different barrel color choline (bottom). Note lack of circumferential red coloration on succinylcholine, and circumferential red band. reducing visual discrimination of commonly used syringes.

Dear SIRS refers to the Safety Information Response System. The purpose of this column is to allow expeditious communication of technology-related safety concerns raised by our readers, with input and responses from manufacturers and industry representatives. Dr. Jeffrey Feldman, current chair of the Committee on Technology, is overseeing the column and coordinating the readers' inquiries and the responses from industry. The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. APSF NEWSLETTER June 2018 PAGE 21

Dear SIRS SAFETY INFORMATION RESPONSE SYSTEM

Change in Prefilled Syringe Labels From “Dear SIRS,” Preceding Page REFERENCES in-Chief, Dr. Greenberg. Our syringe labels 1. Makwana S, Basu B, Makasana Y, et al. Prefilled were enhanced using our in-house digital William R. Hand, MD, FASA syringes: An innovation in parenteral packaging. printing press, and quickly deployed to the Vice-Chair of Academics International Journal of Pharmaceutical Investi- entire US hospital market. As a market leader Department of Anesthesiology gation 2011;1:200-206. in prefilled syringes for anesthesia use in US University of South Carolina School of 2. ASTM D4774-11e1. Standard Specification for Medicine. Greenville, SC User Applied Drug Labels in Anesthesiology. hospitals, the Nephron CGMP quality team Available at: https://www.astm.org/Standards/ continuously monitors all aspects of product Vito Cancellaro, MD D4774.htm quality. We welcome input from the dedicated Chairman Department of Anesthesiology professionals working with APSF. Greenville Health System Reply: Greenville, SC Nephron Pharmaceuticals is a firm with Sincerely, over 20 years of sterile pharmaceutical manu- Lou Kennedy Neither author has any relevant disclosures related Chief Executive Officer to the content of this letter. facturing experience. We appreciate the work of Dr. Hand, Dr. Cancellaro, and APSF Editor- Nephron Pharmaceuticals Corporation

LETTER TO THE EDITOR: In Response to “Carbon Dioxide Used as Insufflating Gas May Raise

ETCO2 During GI Endoscopy”

To the Editor: flation in healthy patients versus patients with subclinical pulmonary dysfunction or actual We commend Dr. Berry for his insightful COPD. These studies showed no difference in Letter to the Editor regarding carbon dioxide the rate of CO rise, peak CO , or SpO , but one (CO ) insufflation during GI endoscopy in the 2 2 2 2 showed a positive correlation for risk of CO February 2018 APSF Newsletter. GI endosco- 2 retention with increased procedure time. Dr. pists are moving from air to CO2 as their choice Berry is right to warn providers about the asso- of insufflating gas to facilitate endoscopy. Dr. ciated CO elevations during longer endoscopy Berry warns the readership of real conse- 2 procedures. The study he mentions, Suzuki Joshua W. Sappenfield, MD quences: Assistant Professor of Anesthesiology 2010 et al.,3 involves a specialized, advanced 1) The possibility of elevated measured end- Director, Airway Management Rotation endoscopy procedure (esophageal endo- Medical Director of the Preoperative Clinic tidal CO2 (sometimes >80 mmHg). scopic submucosal resection), with a median Chief of the Perioperative Medicine Division

2) Significant absorption of CO2 in tissue and duration of 122 minutes and a rise in median Department of Anesthesiology University of Florida College of Medicine the vascular system during long procedures, PaCO2 value from a baseline of 28 mmHg to a

leading to a drop in the pH. peak PaCO2 of 39 mmHg. Thankfully, most The authors have no disclosures as they pertain to this article. However, even a PaCO2 of 130 to 160 mmHg upper endoscopies are far shorter (somewhere 4,5 (even up to 250 mmHg), in healthy volunteers, around 4 to 9 minutes). They can often be REFERENCES 1 has been shown to be well tolerated. In the accomplished, as is largely the European expe- 1. Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation case of gastrointestinal endoscopy, the clear- rience, under minimal to moderate conscious in man. Anesthesiology 1959;20:787–798. ance of insufflated CO from the gut is much sedation, or even under no sedation. Current 2. ASGE Technology Committee, Lo SK, Fujii-Lau LL, 2 et al. The use of carbon dioxide in gastrointestinal more rapid than it is for air. The American Soci- evidence suggests that CO2 insufflation is safe endoscopy. Gastrointest Endosc 2016;83:857–65. ety of Gastrointestinal Endoscopists (ASGE) has even in patients with COPD, but further RCTs 3. Suzuki T, Minami H, Komatsu T, et al. Prolonged published a Technology Status Evaluation would be helpful. Dr. Berry sagely advises cau- carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection. Endoscopy Report that discusses in depth the risks and tion and increased vigilance. 2010;42:1021–9. 2 benefits of CO2 insufflation. A robust bibliogra- Respectfully yours, 4. Demiraran Y, Korkut E, Tamer A, et al. The comparison Jeffrey D. White, MD of dexmedetomidine and midazolam used for sedation phy is cited, and 36 randomized controlled trials of patients during upper endoscopy: A prospective, (RCTs) are discussed that speak to the high Associate Professor of Anesthesiology randomized study. Can J Gastroenterol 2007;21:25–9. 2 Medical Director of Non-OR Anesthesia safety profile for CO2 insufflation. Most of 5. Pambianco DJ, Vargo JJ, Pruitt RE, et al. Computer- Associate Medical Director of GI Endoscopy assisted personalized sedation for upper endoscopy these excluded patients with pulmonary dis- Department of Anesthesiology and colonoscopy: a comparative, multicenter ran- ease, yet three studies did compare CO2 insuf- University of Florida College of Medicine domized study. Gastrointest Endosc 2011;73:765–72. APSF NEWSLETTER June 2018 PAGE 22

2018 Corporate Giving Opportunities Your company can support patient safety and education with a gift to the Anesthesia Patient Safety Foundation (APSF). As a 501c3 charitable organization, the APSF can serve your company’s corporate responsibility, charitable giving, and research goals. Companies support the APSF in many ways. Pharmaceutical, medical device, related organizations, and anesthesia practice man- agement companies make it possible for the APSF to fulfill its mission to continually improve the safety of patients during anesthesia care by encouraging and conducting: • safety research and education; • patient safety programs and campaigns; • national and international exchange of information and ideas. With your generous contributions, the APSF can achieve its vision that no patient shall be harmed by anesthesia. If your organization is interested in partnering with the APSF to support patient safety, contact the APSF office at [email protected] or [email protected]

PARTICIPATE IN THE 2018 APSF OPPORTUNITY TO SPONSOR APSF SPONSORSHIP OF TRANSLATIONS CORPORATE ADVISORY COUNCIL STOELTING CONSENSUS CONFERENCE OF THE APSF NEWSLETTER The Anesthesia Patient Safety Foundation The Stoelting Conference, formerly known as One of APSF’s key initiatives is to improve invites you to become a member of our 2018 the Consensus Conference, brings a defined the international exchange of patient safety Corporate Advisory Council (CAC). When group of approximately 125 leaders from periop- information and ideas. To accomplish this in your company becomes a member of the erative professional organizations such as the 2018, we are working with our colleagues CAC, in addition to the benefits of member- American Society of Anesthesiologists (ASA), the and industry partners to make perioperative ship, your company will also be recognized American Association of Nurse Anesthetists patient safety information, guidelines, and as a supporter of the mission of APSF. Some (AANA), the Association of Operating Room recommendations easily obtainable world- of the benefits of membership, depending Nurses (AORN), the American Society of Peri- wide. The seven translated languages will on your level of support and participation, Anesthetic Nurses (ASPAN), and surgical societies include Chinese, Spanish, Portuguese, French, include together with representatives from anesthesia- Arabic, Russian, and Japanese. Data from the • Invitations to participate in the CAC related industries and colleagues from insurance, World Health Organization suggest that 95% human factors, and legal fields. The recommen- meetings and conference calls, and to of the world’s anesthesia professionals will dations from these conferences have led to sig- meet in person once a year to discuss comprehend articles in English or in one of topics pertinent to patient safety and nificant practice changes resulting in improved these languages. industry patient safety. Examples include perioperative fire • Recognition in APSF communications, safety, vision loss, residual neuromuscular block- For more information on sponsoring a online and in print ade, and operating room distractions. The 2018 newsletter translation, please contact Sara • Invitation to APSF events and meetings Stoelting Consensus Conference is September Moser at [email protected]. with executive-level leadership 5–6, 2018, at the Royal Palms Resort in Phoenix,

• Research and collaboration opportunities AZ and is entitled “Perioperative Medication —A TRANSLATION FROM ENGLISH COMMISSIONED BY THE ANESTHESIA PATIENT SAFETY FOUNDATION— • Networking opportunities allowing lead- Safety—Advancing Best Practices.” ニュースレター The Official Journal of the Anesthesia Patient Safety Foundation ers from corporations and APSF to share Maximum Number of Stoelting Conference www.apsf.org ideas and information. Supporters: Four SELECTED ARTICLES FROM THE APSF NEWSLETTER NOVEMBER 2017

Anesthesia Patient Safety Foundation（APSF）は、日本麻酔科学会（JSA）と連携し、日本語版APSFニュースレ ターを作成し、配布することにしました。 JSAの安全委員会がこの企画を担当します。 共通した目標は、 For specific information about the benefits For more information about the benefits of 周術期の患者の安全教育を改善することです。APSF Newsletterの読者は、12万2千人以上おりますが、各 国で25万人までの拡大を目指しています。今後は、さらにスペイン語，中国語，ポルトガル語，アラビア 語，ロシア語の5か国語で発行する計画があります。このプロジェクトの日本における第1版をこのたび出 of corporate membership, please contact sponsoring the Stoelting Conference, please 版できる運びとなりました。今後も、充実した内容になるように努めてまいりたいと思います。

APSF Newsletter日本語版 編集担当： Sara Moser at [email protected]. contact Sara Moser at [email protected]. 飯田宏樹、澤 智博、西川精宣、祖父江和哉

Opportunity to Partner with APSF on Patient Safety Research Grants Steven Greenberg, MD, Hiroki Iida, MD, PhD FCCP, FCCM

APSF Newsletter Japanese Edition Editorial Representatives from Japan: Hiroki Iida, MD, PhD Tomohiro Sawa, MD, PhD Kiyonobu Nishikawa, MD, PhD Kazuya Sobue, MD, PhD The APSF has distributed $12 million in funding for anesthesia patient safety research Professor and Chair, Professor, Professor and Chair, Professor and Chair, Department of Anesthesiology Teikyo University Medical Department of Anesthesiology Department of Anesthesiology and Pain Medicine Information and System Osaka City University Graduate and Intensive Care Medicine Gifu University Graduate Research Center School of Medicine Nagoya City University Graduate projects over its 30-year history, leading to important discoveries that have changed School of Medicine Department of Anesthesia, Teikyo School of Medicine University School of Medicine clinical practices, improved patient outcomes, and supported the career development of APSF Newsletter Japanese Edition Editorial Representatives from U.S.: Steven Greenberg, MD, FCCP, FCCM Edward Bittner, MD, PhD, MSEd Jennifer Banayan, MD Editor-in-chief of the APSF Newsletter Associate Editor, APSF Newsletter Assistant Editor, APSF Newsletter Clinical Associate Professor in the Department Associate Professor, Anaesthesia, Assistant Professor, of Anesthesiology/Critical Care at the Harvard Medical School Department of Anesthesia and Critical Care anesthesia patient safety scientists. The results of these research grants have made sig- University of Chicago, Chicago, IL. Department of Anesthesiology, Critical Care University of Chicago, Chicago, IL. Vice Chairperson, Education in the and Pain Medicine Department of Anesthesiology at NorthShore Massachusetts General Hospital, Boston, MA. nificant contributions to the specialty. University HealthSystem, Evanston, IL. For more information on sponsoring a research grant, please contact Sara Moser at [email protected]. First Japanese edition of selected articles was published in November 2017. APSF NEWSLETTER June 2018 PAGE 23 Anesthesia Patient Safety Foundation

Founding Patron ($425,000) Sustaining Professional Association ($150,000) American Society of Anesthesiologists (asahq.org) American Association of Nurse Anesthetists (aana.com)

2018 Corporate Advisory Council Members (current as of March 31, 2018)

Platinum ($50,000) Gold ($30,000)

PharMEDium Services Becton Fresenius Kabi GE Healthcare ICU Medical Medtronic Preferred Physicians (pharmedium.com) Dickinson (fresenius-kabi.us) (gehealthcare.com) (icumedical.com) (medtronic.com) Medical Risk Retention (bd.com) Group (ppmrrg.com)

Silver ($10,000) Bronze ($5,000) For more information about how your organization can support the APSF mission and participate in the 2018 Corporate Advisory Council, please see page 22 of this newsletter; go to: aspf.org, or contact Masimo Corporation ($20,000) ClearLine MD Omnicell Sara Moser at: [email protected]. Special recognition and thanks to Medtronic for their support and funding of the APSF/Medtronic Patient Safety Research Grant ($150,000).

Community Donors (includes Individuals, Anesthesia Groups, Specialty Organizations, and State Societies)

$15,000 and higher Robert and Debbie Caplan South Carolina Society of Anesthesiologists Mississippi Society of Anesthesiologists Anaesthesia Associates of Massachusetts (in honor of Robert K. Stoelting, MD) TEAMHealth Missouri Academy of Anesthesiologist (in memory of Ellison Pierce, MD) Codonics Texas Society of Anesthesiologists (in Assistants U.S. Anesthesia Partners Daniel J. Cole, MD memory of Hubert Gootee, MD and Val Randall Moore, DNP, MBA, CRNA Jeffrey B. Cooper, PhD Borum, MD) $5,000 to $14,999 Sara Moser (in memory of Dr. Richard J. Kitz) Washington State Society of David Murray, MD American Academy of Anesthesiologists Robert A. Cordes, MD New Hampshire Society of Anesthesiologist Assistants Matthew B. Weinger, MD District of Columbia Society of Anesthesiologists American Association of Oral and Anesthesiologists Maxillofacial Surgeons $200 to $749 New Jersey State Society of Kenneth Elmassian, DO Anesthesiologists Anesthesia Associates of Ann Arbor Daniela Alexianu, MD David M. Gaba, MD Arkansas Society of Anesthesiologists New Mexico Society of Anesthesiologists Envision Healthcorp Georgia Society of Anesthesiologists Marilyn Barton Nova Scotia Health Authority Frank Moya Continuing Education James D. Grant, MD, MBA (in memory of Darrell Barton) Programs Parag Pandya, MD Steven B. Greenberg, MD Amanda R. Burden, MD Indiana Society of Anesthesiologists Lee S. Perrin, MD Steven K. Howard, MD Michael P. Caldwell, MD Minnesota Society of Hoe T. Poh, MD Illinois Society of Anesthesiologists Joan M. Christie, MD Anesthesiologists Marlene V. Chua, MD Neela Ramaswamy, MD Iowa Society of Anesthesiologists Robert K. Stoelting, MD Jerry Cohen, MD Christopher Reinhart, CRNA Ivenix, Inc Tennessee Society of Colorado Society of Anesthesiologists Patty Mullen Reilly, CRNA Anesthesiologists (in honor of Steve Greenberg, MD; S. Mark Poler, MD; Tom Krejcie, MD; Lauren Glenn E. DeBoer, MD David Rotberg, MD US Anesthesia Partners of Colorado Berkow, MD) John K. Desmarteau, MD Christina Sams, CAA Valley Anesthesiology Foundation Kaiser Permanente Nurse Anesthetists Stephen B. Edelstein, MD Sanford Schaps, MD Mary Ellen and Mark A. Warner Association (KPNAA) Jan Ehrenwerth, MD Julie Selbst, MD (in honor of Robert K. Stoelting, MD) Kentucky Society of Anesthesiologists Jeffrey Feldman, MD, MSE Society for Obstetric Anesthesia and $2,000 to $4,999 James J. Lamberg, DO Sara Goldhaber-Fiebert, MD Perinatology (in honor of Robert K. Stoelting, MD) Academy of Anesthesiology Cynthia A. Lien, MD Dr. David Solosko and Ms. Sandra Kniess Lorri A. Lee, MD Florida Academy of Anesthesiologist Kansas City Society of Anesthesiologists Assistants Steven L. Sween, MD Massachusetts Society of Anesthesiologists (In honor of Robert K. Stoelting, MD) Madison Anesthesiology Consultants Jeremy Geiduschek, MD (in memory of Drs. Bill and Hoffman) Mark C. Norris, MD Allen N. Gustin, MD James F. Szocik, MD Massachusetts Society of Anesthesiologists Ohio Academy of Anesthesiologist Alexander Hannenberg, MD Joseph W. Szokol, MD Michigan Society of Anesthesiologists Assistants (in honor of Mark A. Warner, MD) Stephen J. Thomas, MD Michael D. Miller, MD Ohio Society of Anesthesiologists Kansas State Society of Anesthesiologists Rebecca S. Twersky, MD Brandon M. Moskos, AA Oklahoma Society of Anesthesiologists Catherine M. Kuhn, MD Benjamin Vacula, MD (in memory of Bill Kinsinger, MD) George and Jo Ann Schapiro James Lamberg, DO Ronald Valdivieso, MD Oregon Society of Anesthesiologists Della M. Lin, MD Springfield Anesthesia Service at Timothy Vanderveen James M. Pepple, MD Dr. Kevin and Janice Lodge Baystate Medical Center Andrea Vannucci, MD Physician Specialists in Anesthesia Wisconsin Society of Anesthesiologists Jamie Maher (in honor of William D. Owens, MD) (Atlanta, GA) (in memory of Bill Kissinger, MD) Maria VanPelt, PhD, CRNA $750 to $1,999 May Pian-Smith, MD, MS Maine Society of Anesthesiologists Douglas A. Bartlett (in honor of Dr. Warren Zapol) Kurt Markgraf, MD Virginia Society of Anesthesiologists (in memory of Diana Davidson, CRNA) Lynn Reede, CRNA Maryland Society of Anesthesiologists Gina Whitney, MD Casey D. Blitt, MD Society for Ambulatory Anesthesia Edwin Mathews, MD G. Edwin Wilson, MD

Note: Donations are always welcome. Donate online (http://www.apsf.org/donate_form.php) or mail to APSF, Mayo Clinic, Charlton 1-145, 200 First Street SW, Rochester, MN 55905. (Donor list current from April 1, 2017–March 31, 2018.) APSF NEWSLETTER June 2018 PAGE 24 Dear SIRS: SAFETY INFORMATION RESPONSE SYSTEM

Not All Manifolds are the Same: Lessons in Intravenous Drug Administration Dear SIRS: Providers should be aware that the possibil- ing phenylephrine drug was attached to the ity of downstream aspiration of medications is I am writing to describe an incident we manifold. A second syringe was attached to the possible when syringes are left connected to experienced at The University of Texas MD IV line downstream from the manifold and used Anderson Cancer Center that has implica- certain types of manifolds, especially those as a “pump” to create negative pressure, which without built in stopcocks. Figure 2 shows vari- tions for providers administering intravenous resulted in the liquid from the phenylephrine ous colored dyes being pulled into a manifold medications, particularly in the operating syringe being introduced into the IV line. The when aspiration is performed downstream. room. In order to add port sites to a blood set, check valves incorporated into the MultiPort a Quest Medical six channel manifold was Figure 3 demonstrates how contents from device are passive, or a “floating disc” design, placed in line and a stopcock was placed in syringes left on manifolds with stopcocks the tubing between the patient and the mani- (orange/red dyes) do not allow for downstream which simply open or close based on a pressure fold (Figure 1). Later in the case, blood was aspiration, while aspiration is possible with differential. The purpose of a passive check valve administered during an episode of hypoten- manifolds without stopcocks that have is to prevent drugs/fluids injected from one port sion and a 20ml syringe was connected to syringes freely connected to them (blue dye). from entering another port on the manifold. A this stopcock to act as a pump, allowing the This could lead to clinically important conse- passive check valve will not prevent positive flow quences, such as unintended medication periodic aspiration and injection of blood. A if a vacuum condition is created downstream sudden increase in blood pressure was seen administration. Providers should practice vigi- from the manifold. Quest Medical concludes that and it was noted that a syringe of phenyleph- lance and disconnect any syringes from mani- rine that had been left on the manifold was folds/port sites that are not actively being used the device performed as intended. Quest Medical now empty. It was determined that 2ml of to administer medications. does offer alternative manifolds that incorporate phenylephrine (100mcg/mL) had inadver- the use of positive pressure valves, which may be Ravish Kapoor MD tently been administered to the patient. The more suitable for your unique method of use. Assistant Professor blood pressure response was temporary, Department of Anesthesiology Thank you for providing feedback on the use and within 20% of the patient’s baseline blood & Perioperative Medicine performance of our products. Our objective is to pressure, and started to fade within minutes. The University of Texas MD Anderson provide high quality medical devices. Your input is Cancer Center valuable in support of Quest Medical’s goal of Reply: continuous improvement. Patient Fluids A unique method for actively pumping blood in Jan Hodges an IV line has been demonstrated, which con- Director, Quality Assurance & Regulatory Affairs tained our MultiPort® manifold. A syringe contain- Quest Medical, Inc.

Figure 1: Set up of iv tubing, manifold, and downstream stopcock that could potentially allow for inadvertent aspiration if performed at the level of the stopcock and syringes are freely connected to the manifold.

Figure 2: Aspiration downstream allowing the Figure 3: Notice how contents of syringes connected to manifold with stopcocks are not aspirated down- contents of multiple syringes connected to an stream (orange/red dyes), but aspiration of contents from syringe attached to manifold without stopcocks is in-line manifold to be drawn inside the iv tubing. possible (blue colored dye).

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. APSF NEWSLETTER June 2018 PAGE 25

Preventing Surgical Site Infection After Cesarean Delivery—The Anesthesia Professional's Role by: Katherine M Seligman, MD; Daniel Katz, MD; Michaela K Farber, MD

I. BURDEN OF SURGICAL SITE Figure 1: Bundle components can work synergistically to decrease rates of surgical site INFECTIONS infections and improve patient outcomes. Surgical site infections (SSIs) represent a sig- nificant portion of health care morbidity and expense in the United States (US). While SSIs complicate 1.9% of all surgeries performed, the incidence of SSI after cesarean delivery (CD) is Mitigate Risk Glycemic Maintain Antibiotic Patient substantially higher, 7-10%.1-3 As CDs are the Factors Control Normothermia Prophylaxis Education most common surgery performed in the US (>1.2 million performed per year), post-CD SSI is a significant cause of increased morbidity, mor- tality, readmission, and prolonged hospitaliza- tion.4 The estimated cost burden for SSI after II. CLASSIFICATION AND guidelines for the classification and surveillance of SSIs diagnosed within 30 days of surgery.1,7,8 cesarean delivery is $2852–$3842 per case in RISK FACTORS OF SSI the US.5 Recognition and implementation of Surgical site infections include superficial and Identification of risk factors for the develop- evidence-based initiatives with a bundle deep incisional infections as well as organ space ment of SSIs after CD may help define modifiable approach to prevent and reduce SSI after CD infections.1 Incisional infection after CD occurs in points in obstetric care and lower the incidence of SSIs.7 Patient-related risk factors include ele- may aid in optimizing maternal safety, while 2-7% of cases; necrotizing fasciitis in 0.18%; and vated BMI, diabetes, asthma, smoking, recurrent reducing cost. endometritis in 2-16%.6 The CDC has released pregnancy loss, and ASA classification >3.9-11 There is myriad evidence in the general surgical Table 1: Sample SSI Bundle and Phase of Care literature that glucose control and smoking ces- sation decrease rates of surgical site infection.12,13 Intervention Phase of Care To our knowledge, impact of these interventions 4% Chlorhexidine Gluconate shower x 233 Pre-Op in the pregnant population has not been night before & morning of surgery reported. Pregnancy-specific risk factors include hypertensive disorders, gestational diabetes mel- 34 Hair removal with clippers Pre-Op litus, prolonged rupture of membranes, pro- immediately before entering OR longed labor, sexually transmitted infections in Glycemic control Pre-Op, Intra-Op, pregnancy, chorioamnionitis, and multiple gesta- 9-11 Blood glucose < 126 mg/dl* (Pre-op, Intra-op)17 Post-Op tions. Procedure-related risk factors include Blood glucose < 200 mg/dl (Post-Op)8,18 increased operative time (> 38 min), bowel injury, use of staples, non-closure of subcutaneous 21,22  Appropriate antibiotic administration within 1 hour of skin incision* Pre-Op tissue if greater than 2 cm, and the inappropriate < 120 kg – 2 g Cefazolin use of perioperative antibiotics.9-11,14 Emergent CD ≥ 120 kg – 3 g Cefazolin has been implicated, but has not been directly + correlated with increased risk for SSI. 500 mg Azithromycin if ruptured membranes III. DEVELOPING A SSI BUNDLE Maintain normothermia, maternal temp. > 36°C*26 Pre-Op, Intra-Op, The Institute for Healthcare Improvement Post-Op introduced the concept of “bundles” as a way to Chlorhexidine with alcohol skin prep35 Pre-Op adopt evidence-based guidelines into practice to improve patient outcomes and care (Figure Providone Iodine vaginal prep36 Pre-Op 1).15 Institutions that have implemented SSI bun- Umbilical cord traction for placental delivery37 Intra-Op dles to decrease rates of infection following CD have seen statistically significant decreases in 23 Antibiotic re-dosing if EBL > 1500 mL or time > 4 hrs Intra-Op postoperative complications.5,16 Although sur- Glove change prior to fascia closure38 Intra-Op geons dictate most of the interventions to decrease SSI, there are a few important circum- Subcutaneous tissue closure with suture for depth > 2 cm39 Intra-Op stances where the anesthesia professional may intervene. The following section will outline evi- Skin closure with suture35 Intra-Op dence-based bundle components that an anes- Dressing removal between 24–48 hrs8 Post-Op thesia professional may implement to decrease

32 SSIs. An example bundle containing nursing, Patient education on wound care & signs of SSI* Post-Op surgical, and anesthesia components is shown in Table 1. * Indicates where anesthesia professional may have a collaborative role in the interventions. See “SSI,” Next Page APSF NEWSLETTER June 2018 PAGE 26

Proposed Cesarean Section SSI Prevention Bundle Elements

From “SSI,” Preceding Page NORMOTHERMIA Dr. Katz is an Assistant Professor in the Department of Anesthesiology, Perioperative & GLYCEMIC CONTROL Perioperative hypothermia is associated with increased wound infection, length of hospital Pain Medicine at Icahn School of Medicine at Peripartum normoglycemia for women with stay, and increased morbidity and mortality for Mount Sinai in New York. diabetes is associated with improved fetal and premature infants.24,25 Maternal temperature Dr. Farber is an Assistant Professor, Obstetric maternal outcomes. Conversely, perioperative should be monitored intraoperatively and post- Anesthesia Fellowship Director, and Associate hyperglycemia is a noted risk factor for post CD operatively with a goal perioperative maternal Division Chief of Obstetric Anesthesia in the SSI.5,9 Further benefits to maintaining a normal temperature of >36.0 °C per WHO guidelines.26 Department of Anesthesiology, Perioperative & range of maternal glucose (70–126 mg/dL) The anesthesia professional may consider a Pain Medicine at Brigham and Women’s Hospi- include lowering the risks of neonatal hypogly- temporal thermometer or foley temperature tal in Massachusetts. cemia and maternal ketoacidosis.17 Women with probe as the patient is awake. Skin temperature a diagnosis of diabetes should have a blood None of the authors have any disclosures. probes can vary from core temperature by sugar evaluated preoperatively. Elevated blood 0.5-2 °C and may be used taking this into The information provided is for safety-related glucose should be treated with insulin. If a account.27 The use of forced air warmers and educational purposes only, and does not constitute patient receives insulin, blood glucose should medical or legal advice. Individual or group responses increasing operating room temperature have be re-evaluated within 30–60 minutes of are only commentary, provided for purposes of been shown to decrease rates of perioperative administration.18 If the surgical procedure is >1 education or discussion, and are neither statements of 28,29 advice nor the opinions of APSF. It is not the intention hour in duration, a bedside glucose level can be hypothermia in parturients and neonates. The anesthesia professional may consider of APSF to provide specific medical or legal advice or obtained intraoperatively to guide treatment. A to endorse any specific views or recommendations in blood glucose level should also be obtained in setting the OR temperature to 22.5 °C (72 °F) response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for the PACU.19 According to the CDC guidelines, a and placing an upper and/or lower body forced air warmer to ensure normothermia is main- any damage or loss caused or alleged to be caused more liberal yet controlled postoperative glu- 8 by or in connection with the reliance on any such cose target of < 200 mg/dl may decrease mor- tained. Intraoperative temperature may also information. be obtained every 15–30 minutes and docu- bidity associated with hypoglycemic events 30 and strict glycemic control, while still potentially mented. REFERENCES reducing rates of SSI. However, these data orig- PATIENT EDUCATION 1. Centers for Disease Control Surgical Site Infection (SSI) Event. 2018. https://www.cdc.gov/nhsn/pdfs/ inated from the non-obstetric surgical popula- SSI prevention requires adherence to guide- pscmanual/9pscssicurrent.pdf. Accessed March 13, tion, and further studies for post-cesarean lines by surgeons, nurses, and anesthesia pro- 2018. delivery patients are warranted.8,18,20 fessionals as well as participation by patients 2. Yokoe DS, Christiansen CL, Johnson R, et al. Epidemiol- and their families.31 Patient education surround- ogy of and surveillance for postpartum infections. Emerg Infect Dis 2001;7:837–841. PREOPERATIVE ANTIBIOTICS ing postoperative wound care, appropriate 3. Conner SN, Verticchio JC, Tuuli MG, et al. Maternal obe- The American College of Obstetricians and hand hygiene for patient/staff/family, and signs sity and risk of postcesarean wound complications. Am J Gynecologists (ACOG) guidelines recommend of infection should be delivered preoperatively Perinatol 2014;31:299–304. the administration of a first generation cephalo- as well as postoperatively.32 The anesthesia 4. Curtin SC, Gregory KD, Korst LM, et al. Maternal morbid- sporin within 1 hour prior to incision, dosed ity for vaginal and cesarean deliveries, according to pre- professional may emphasize strict adherence vious cesarean history: new data from the birth according to maternal body weight (cefazolin to hand washing and be vigilant about detect- certificate, 2013. Natl Vital Stat Rep 2015;64:1–13, 2 g IV if <120 kg; cefazolin 3 g IV if ≥120 kg). The ing early signs of infection that may occur at any 5. Kawakita T, Landy HJ. Surgical site infections after cesar- previous practice of dosing antibiotics after cord point of their patient interaction, such as fever, ean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol 2017;3:12. clamping has been shown to increase rates of tachycardia, vasopressor requirement, or leuko- 21 6. Olsen MA, Butler AM, Willers DM, et al. Attributable costs infection and should be abandoned. A recent cytosis. of surgical site infection and endometritis after low trans- study suggests that azithromycin 500 mg IV verse cesarean delivery. Infect Control Hosp Epidemiol administered prior to incision in non-elective IV. CONCLUSION 2010;31:276–282. CD, in addition to a cephalosporin, decreased Evidence-based interventions that demand a 7. Rubin RH. Surgical wound infection: epidemiology, 22 multidisciplinary team approach have proven pathogenesis, diagnosis and management. BMC Infect the rate of SSI by half. However, further valida- Dis 2006;6:171. tion with assurance of primary cephalosporin effective for decreasing the incidence of post- 31 8. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Cen- coverage will be important to refine the target CD SSIs. Integrating change in a hospital ters for Disease Control and Prevention Guideline for the population who will most benefit from this system, from identifying evidence-based mea- Prevention of Surgical Site Infection, 2017. JAMA Surgery 2017;152:784–791. adjunct. Patients with anaphylaxis to penicillin sures that reduce post-CD wound infections to the final step of applying and tracking such 9. Moulton LJ, Munoz JL, Lachiewicz M, et al. Surgical site can receive clindamycin 900 mg IV and genta- infection after cesarean delivery: incidence and risk fac- mycin 5 mg/kg IV (dosing weight) prior to inci- measures, works best if a team approach is tors at a US academic institution. J Matern Fetal Neona- sion, although local antibiotic resistance used integrating obstetrics, anesthesia, nursing, tal Med 2017:1–8. and quality. The ultimate goal of a SSI bundle is 10. Krieger Y, Walfisch A, Sheiner E. Surgical site infection patterns may dictate the use of vancomycin or following cesarean deliveries: trends and risk factors. J other antibiotics depending on these patterns.21 to eliminate deviations from standard of care Matern Fetal Neonatal Med 2017;30:8–12. The re-dosing of prophylactic antibiotics in the and decrease maternal morbidity and mortality. 11. Killian CA, Graffunder EM, Vinciguerra TJ, et al. Risk fac- setting of postpartum hemorrhage defined as Further research is required to determine which tors for surgical-site infections following cesarean sec- tion. Infect Control Hosp Epidemiol 2001;22:613–617. >1500 mL estimated blood loss, and also after set of interventions optimize improvement in patient outcomes. 12. Nolan MB, Martin DP, Thompson R, et al. Association two half-lives of the medication have passed, between smoking status, preoperative exhaled carbon are additional strategies that may reduce post- Dr. Seligman is an Assistant Professor and monoxide levels, and postoperative surgical site infec- 23 Division Chief of Obstetric Anesthesia in the tion in patients undergoing elective surgery. JAMA Sur- CD SSIs. Further studies are required in the gery 2017;152:476–483. parturient population to definitively validate Department of Anesthesiology and Critical Care these redosing recommendations. Medicine at the University of New Mexico. See “SSI,” Next Page APSF NEWSLETTER June 2018 PAGE 27

Cesarean Delivery SSI Prevention Bundle From “SSI,” From Preceding Page 23. Fay KE, Yee L. Applying surgical antimicrobial standards October 28, 2016). https://www.asahq.org/~/media/Sites/ in cesarean deliveries. Am J Obstet Gynecol 2018; ASAHQ/Files/Public/Resources/standards-guidelines/ 13. May AK, Kauffmann RM, Collier BR. The place for glyce- 218:416.e1-416.e4. standards-for-basic-anesthetic-monitoring.pdf. mic control in the surgical patient. Surgical Infections Accessed April 2018. 2011;12:405–418. 24. de Almeida MF, Guinsburg R, Sancho GA, et al. Hypo- 31. Carter EB, Temming LA, Fowler S, et al. Evidence-Based 14. Opoien HK, Valbo A, Grinde-Andersen A, et al. Post- thermia and early neonatal mortality in preterm infants. J bundles and cesarean delivery surgical site infections: a cesarean surgical site infections according to CDC stan- Pediatr 2014;164:271–275 e271. systematic review and meta-analysis. Obstetrics and dards: rates and risk factors. A prospective cohort study. 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Cochrane Database hyperglycemia management—an Update. Anesthesiol- Syst Rev 2014;12:Cd007892. ogy 2017;126:547–560. adults. Cochrane Database Syst Rev 2016;4:CD009016. 37. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of deliv- 20. Vriesendorp TM, Morelis QJ, Devries JH, et al. Early post- 29. Duryea EL, Nelson DB, Wyckoff MH, et al. The impact of ering the placenta at caesarean section. Cochrane Data- operative glucose levels are an independent risk factor for ambient operating room temperature on neonatal and base Syst Rev 2008;3:Cd004737. infection after peripheral vascular surgery. A retrospective maternal hypothermia and associated morbidities: a ran- study. Eur J Vasc Endovasc Surg 2004;28:520–525. 38. Reddy B, Scrafford J. Effect of Intra-Operative Glove- domized controlled trial. Am J Obstet Gynecol Changing During Cesarean on Post-Op Complications: A 21. ACOG Practice Bulletin No. 120: Use of prophylactic anti- 2016;214:505.e501–507. Randomized Controlled Trial [12OP]. Obstetrics & Gyne- biotics in labor and delivery. Obstetrics and Gynecology cology 2017;129:4S–5S. 2011;117:1472–1483. 30. Standards for basic anesthetic monitoring. Committee of Origin: Standards and Practice Parameters. (Approved 39. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure 22. Tita AT, Szychowski JM, Boggess K, et al. Adjunctive of subcutaneous fat and wound disruption after cesar- by the ASA House of Delegates on October 21, 1986, last azithromycin prophylaxis for cesarean delivery. The New ean delivery: a meta-analysis. Obstetrics and Gynecol- N Engl J Med 2016;375:1231–1241. amended on October 20, 2010, and last affirmed on ogy 2004;103:974–980.

ANNOUNCEMENT APSF Safety Recognition Award Best Practices for Safe Medication Administration during Anesthesia Care Deadline for Submission: June 15, 2018 The Anesthesia Patient Safety Foundation seeks to recognize organizations that have made significant advances in safe medication administra- tion during anesthesia care. Best practices of safe medication administration covered by the STPC paradigm*—Standardization, Technology, Phar- macy, Culture—will be considered. Special consideration will be given to practices with processes that complement patient care workflow and integrate documentation with the EHR. Evidence indicating improved medication safety is most desirable, but it is recognized that qualitative evi- dence of process improvement (e.g., surveys of user acceptance) may be the best available evidence. Actual implementation experience in patient care is also required rather than ideas that have yet to be implemented. Submissions should be limited to 1500 words and include the following: • A description of the objective(s) of the practice including the aspect(s) of the STPC approach that are incorporated • A description of the clinical workflow designed to support the practice • Integration with the electronic health record • The duration of time the practice has been in use • The approximate number of patients impacted since implementation • Methods used to evaluate effectiveness Awardees will be invited to the upcoming Stoelting Conference on Medication Safety in Anesthesia to be held September 5, 2018, in Phoenix, AZ, to receive the award and present their work. They will also be recognized with a certificate from the APSF and publication of their work in the APSF Newsletter, website, and social media feeds. Submissions will be reviewed by members of the APSF Committee on Technology. The award will be approved by the APSF Board of Directors and announced by August 1, 2018. Award Applications should be submitted to Yulonda Motley, Assistant to Jeffrey M. Feldman, MD, Chair, APSF Committee on Technology at [email protected]. *STPC Paradigm: https://www.apsf.org/resources/med-safety/ APSF NEWSLETTER June 2018 PAGE 28

Systemic Lidocaine: An Effective and Safe Modality for Postoperative Pain Management and Early Recovery by Brent Earls, MD, and Lisa Bellil, MD Since its development in 1943, lidocaine has been a versatile medication in the armament of the anesthesia professional. Originally used as an anti-arrhythmic drug, it wasn’t long before its impact on pain was discovered.1 The earliest articles published showing pain reduc- tion came out in the 1960s. Possibly due to the current opioid epidemic or perhaps because of the adoption of early recovery protocols and the concept of multimodal surgical care, lidocaine for analgesia has seen a re-emer- gence. From use in chronic pain syndromes to open abdominal surgery, lidocaine infusions have been incorporated and found to have positive results with a well-tolerated side effect profile. The antinociceptive properties of sys- temically administered lidocaine have repeat- edly been shown in various experimental and clinical pain conditions.2-5 Some literature sug- gests that systemic administration of lidocaine may confer anti-metastatic benefits in some cancer patients.6 Studies have shown lidocaine to have a glycine-like action in the central ner- 10 micrograms per milliliter of hydromorphone ness, tinnitus, or headache. There were no seri- vous system at plasma levels far below what is through the epidural.11 It comes as no surprise ous adverse events reported from these trials required to prevent nerve impulse generation. that thoracic and lumbar epidural analgesia or poor surgical outcomes related to the lido- The role of lidocaine in chronic inflammatory does provide better pain relief at late time caine infusion reported in the treatment arm of conditions is a much more recent area of points, although studies are showing intrave- the trials reviewed. Despite the more than 40 research. Changes in expression of sodium- nous (IV) lidocaine to be a great alternative in trials included in the review, more high-quality channel isoforms are involved, and lidocaine is patients who refuse neuraxial methods or have evidence is needed to delineate the clinical believed to have its effect at these sites in the contraindications and can provide great analge- 7 effect that can be expected with this modality. dorsal root ganglion. Additionally, lidocaine has sia up to two days after surgery.11-13 been shown to modulate N-methyl-D-aspartate The Cochrane review concluded that there was (NMDA) receptors, which could contribute to When administering a lidocaine infusion, it is low to moderate evidence. The authors also the prevention of chronic pain states.8,9 The important to discuss this plan with the surgical noted a scarcity of studies evaluating optimal therapeutic index of lidocaine has been investi- team prior to administering the infusion as well dose, adverse effects, and timing, and further gated by several researchers and found to as to check for any contraindications in each research is likely to have an important impact have optimum effects at 2–10 μg/mL2 and a patient (Table 1). Fortunately, lidocaine has a long- on the confidence in the estimate of effect.16 proven track record for safety as an IV medica- total duration of 24–48 hours from the start of Rimback et al. compared systemic lidocaine tion and has been very well tolerated in the trials the infusion. Achieving and maintaining this (3 mg/min) versus normal saline placebo in 30 level can be dependent on patient co-morbidi- investigating the efficacy of this method.12,14,15 patients undergoing elective cholecystectomy ties, age, and other factors that should be con- In 2015, a Cochrane review, which included in the early 1990s. They found reduced need sidered on a patient-by-patient basis.10 45 trials, was published comparing the effect of for opioids, earlier return of bowel function, Lidocaine infusions have influenced numer- continuous perioperative lidocaine infusion and shorter hospital stays. This group pro- ous clinical outcomes investigated by either with placebo, or no treatment, or with epi- posed a mechanism of less peritoneal irritation researchers. Terkawi et al. conducted a trial dural analgesia in adults under general anes- thus reducing inhibitory gastrointestinal including 216 patients and found lidocaine thesia. The epidurals contained various reflexes.14 Several randomized, placebo-con- solutions of dilute local anesthetics with or with- infusion to be equal with respect to pain trolled clinical trials have demonstrated that IV out low-dose opioids. The results suggested scores to epidural analgesia in adults under- lidocaine administration similarly reduces the going abdominal or pelvic surgery. They also that the lidocaine infusion group had a reduc- duration of postoperative ileus and need for found lower incidence of postoperative tion in postoperative pain at early and interme- narcotic pain control, thus accelerating hospi- nausea and vomiting, pruritus, and urinary diate time points, expedited gastrointestinal tal discharge.12,14,15,17 In this early study, Rim- retention. However, the intravenous lidocaine recovery time, reduced postoperative nausea/ bäck et al. implied that lidocaine infusions group, receiving 1 mg/kg per hour for up to 96 vomiting and opioid usage as well as a reduc- hours postoperatively did have higher sys- tion in hospital length of stay.16 There was lim- might reduce inflammation by blunting the temic opioid consumption when compared to ited data on adverse effects in the studies with sympathetic response and the associated the epidural analgesia group, who received a the lidocaine intervention. However, most inflammatory cascade. combination of 0.125% bupivicaine and reported events were limited to light-headed- See “Lidocaine Infusion,” Next Page APSF NEWSLETTER June 2018 PAGE 29

Pain Programs May Manage Lidocaine Infusions Safely With Appropriate Monitoring

From “Lidocaine Infusion,” Preceding Page Table 1: Contraindications for date, we have not had any severe complications 26 Herroeder et al. performed a double-blind, Lidocaine Infusion using our lidocaine infusion protocol since its implementation in the fall of 2017. Trials pub- randomized, controlled study in 60 patients Sensitivity or allergy to lidocaine lished using infusion rates for pain control docu- undergoing colorectal surgery. Their results ment very few minor symptoms, which are suggested that with systemic lidocaine Significant heart disease (i.e., 2nd or 3rd self-limiting. Patients have noted symptoms (1.5 mg/kg bolus followed by a 2 mg/min infu- degree heart block, Exception: Patients with including light-headedness, dizziness, tinnitus, or sion), patients were afforded shorter hospital a pacemaker) metallic taste in their mouth that resolve soon stays and earlier return of bowel function. They Severe cardiac failure (Ejection fraction after discontinuation of the infusion. At this time, were also able to show a measured reduction < 20%) we recommend patients be monitored on the of a variety of inflammatory cytokines in the sys- floor with continuous pulse oximetry without the temic lidocaine group.15 This study was able to History of Adams-Stokes, Wolff-Parkinson- need for routine telemetry. The lidocaine infusion showcase not only the central analgesic prop- White Syndrome or active dysrhythmia is continued for 24 to 48 hours from initiation, as erties of local anesthetics but also the anti- Concurrent treatment with Class I antiar- this is in line with the optimal clinical effect inflammatory properties. This significant rhythmics or amiodarone use < 3 months reported in most published trials we have inves- reduction in inflammatory mediators has impli- Severe hepatic impairment (bilirubin tigated.11-15,17,18,25 Our acute pain service will con- cations in not only return of bowel function and > 1.46 mg/dl) tinue to follow up for an additional day to provide postoperative ileus but also thrombosis, post- an extra layer of patient safety and continue to operative myocardial infarction, and sepsis.18 Severe renal impairment (<30mL/min/1.73 m2 or ESRD) assist with pain management as needed. At Medstar Georgetown University Hospital, History of uncontrolled seizure Dr. Earls is an R2 (PGY-2) anesthesiology resi- we have eagerly adopted IV lidocaine infusions dent at Medstar Georgetown University Hospital. as part of a balanced anesthetic plan. Several Acute porphyria surgeons regularly incorporate IV lidocaine Dr. Bellil is Director of Obstetric Anesthesia, infusions into their perioperative treatment pro- former Director of Acute Pain Service and Assis- After the patients are brought to the recovery tocols. It is used as a fundamental component tant Professor in the Department of Anesthesiol- room, our acute pain service takes over the man- of our early recovery protocol in combination ogy at Medstar Georgetown University Hospital. agement of the lidocaine infusion. This is an with acetaminophen, gabapentin, and cele- important step in maintaining safety during the Neither of the authors have any disclosures relevant coxib. This protocol is incorporated into most infusion period to have early recognition of local to this article. patients’ care undergoing colorectal surgery19 anesthetic toxicity. Our staff will monitor patients or, cholecystectomy; however, it has been used Special acknowledgment to Dr. David Dickerson, at least every four hours for lightheadedness or the Director of the Acute Pain Service and Assistant successfully in select patients not undergoing dizziness, visual and auditory disturbances, or Professor in the Department of Anesthesia & Critical abdominal surgery. Patients are evaluated on metallic taste and are available at all times for any Care at the University of Chicago for serving as an individual basis for candidacy of each medi- guest editor. concerns. Unfortunately, our clinical laboratory cation. A thorough history and physical exam processes serum lidocaine as a send-out labora- The information provided is for safety-related are performed to rule out contraindications to tory value, and, therefore, it can take up to three educational purposes only and does not constitute lidocaine (Table 1). medical or legal advice. Individual or group days to obtain a result, which limits its use in clini- responses are only commentary, provided for During induction, the systemic administration cal practice. Therefore, if our staff recognizes or purposes of education or discussion, and are neither is started with a one-time bolus of 1–1.5 milli- has suspicion of early signs of toxicity, the infu- statements of advice nor the opinions of APSF. It is grams per kilogram ideal body weight (IBW) after sion is discontinued and the patient is moved to not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or which time an infusion is initiated at 2 milligrams an intermediate care unit for continuous teleme- recommendations in response to the inquiries per kilogram per hour (IBW). This rate is contin- try. Our protocol utilizes the Checklist for Local posted. In no event shall APSF be responsible or ued for the first four hours and then reduced to 1 Anesthetic Systemic Toxicity (LAST) published by liable, directly or indirectly, for any damage or loss milligram per kilogram per hour for the remain- the American Society of Regional Anesthesia caused or alleged to be caused by or in connection with the reliance on any such information. der of the infusion period. Reducing the infusion and Pain Medicine.23 As an additional precau- rate after the first four hours is an effective and tion, the pharmacy will stock 20% IV fat emulsion REFERENCES simple method to avoid toxic levels of lidocaine, in the automated medication dispensing system 1. Bartlett EE, Hutserani O. Xylocaine for the relief of but maintain a therapeutic concentration for pain of floors where patients are receiving the infu- postoperative pain. Anesth Analg 1961;40:296–304. 20 2. Tanelian DL, MacIver MB. Analgesic concentrations of control. Biotransformation of lidocaine yields sion for quick access in case of emergency. lidocaine suppress tonic A-delta and C fiber dis- metabolites monoethylglycinexlidide (MEGX) Because lidocaine levels would not be pro- charges produced by acute injury. Anesthesiology and glycine xylidide (GX). The systemic actions cessed in a clinically useful timeframe, it is impor- 1991;74:934-936. of these metabolites are similar to, but less tant for us to recognize dangerous clinical signs 3. Woolf CJ, Wiesenfeld-Hallin Z. The systemic adminis- tration of local anaesthetics produces a selective potent than, lidocaine itself and are most pro- and initiate treatment early. These signs include depression of C-afferent fibre evoked activity in the nounced when combined with concomitant hypotension, seizure, loss of consciousness, and spinal cord. Pain 1985;23:361–374. administration with lidocaine. Pharmacokinetics very late signs can include respiratory arrest and 4. Basbaum AI. Distribution of glycine receptor immuno- 24 reactivity in the spinal cord of the rat: cytochemical of these metabolites can be diminished in indi- cardiac arrhythmia or arrest. If these signs are evidence for a differential glycinergic control of viduals with liver cirrhosis21 and has even been witnessed or suspected, the acute pain service lamina I and V nociceptive neurons. J Comp Neurol developed as a more sensitive index than the attending physician is immediately notified and 1988;278:330–336. Pugh score for liver dysfunction.22 will determine the need for lipid emulsion. To See “Lidocaine Infusion,” Next Page APSF NEWSLETTER June 2018 PAGE 30

Lidocaine Infusion for Perioperative Pain Management

From “Lidocaine Infusion,” Preceding Page pain intensity and bowel function after major large 19. Kaba A, Laurent SR, Detroz BJ, et al. Intravenous lido- bowel surgery: a double-blind randomized controlled caine infusion facilitates acute rehabilitation after lap- 5. Abram SE, Yaksh TL. Systemic lidocaine blocks nerve trial. J Gastrointest Surg 2014;18:2155–2162. aroscopic colectomy. Anesthesiology 2007;106:11–18; injury-induced hyperalgesia and nociceptor-driven discussion 15–16. spinal sensitization in the rat. Anesthesiology 13. Wongyingsinn M, Baldini G, Charlebois P, et al. 1994;80:383–391. Intravenous lidocaine versus thoracic epidural anal- 20. Wong BY, Hurwitz A. Simple method for maintaining gesia: a randomized controlled trial in patients serum lidocaine levels in the therapeutic range. Arch 6. Chamaraux-Tran TN, Piegeler T. The amide local Intern Med 1985;145:1588–1591. anesthetic lidocaine in cancer surgery—potential anti- undergoing laparoscopic colorectal surgery using metastatic effects and preservation of immune cell an enhanced recovery program. Reg Anesth Pain 21. Thomson AH, Elliott HL, Kelman AW, et al. The phar- function? A Narrative Review. Front Med (Lausanne). Med 2011;36:241–248. macokinetics and pharmacodynamics of lignocaine 2017;4:235. 14. Rimback G, Cassuto J, Tollesson PO. Treatment of and MEGX in healthy subjects. J Pharmacokinet Bio- 7. Amir R, Argoff CE, Bennett GJ, et al. The role of postoperative paralytic ileus by intravenous lidocaine pharm 1987;15:101–115. sodium channels in chronic inflammatory and neuro- infusion. Anesth Analg 1990;70:414–419. 22. Huang YS, Lee SD, Deng JF, et al. Measuring lidocaine pathic pain. J Pain 2006;7(5 Suppl 3):S1–29. 15. Herroeder S, Pecher S, Schonherr ME, et al. Systemic metabolite—monoethylglycinexylidide as a quantita- 8. Muth-Selbach U, Hermanns H, Stegmann JU, et al. lidocaine shortens length of hospital stay after colorec- tive index of hepatic function in adults with chronic Antinociceptive effects of systemic lidocaine: involve- tal surgery: a double-blinded, randomized, placebo- hepatitis and cirrhosis. J Hepatol 1993;19:140–147. ment of the spinal glycinergic system. Eur J Pharma- controlled trial. Ann Surg 2007;246:192–200. 23. Rubin DS, Matsumoto MM, Weinberg G, et al. Local col 2009;613:68–73. 16. Kranke P, Jokinen J, Pace NL, et al. Continuous intra- anesthetic systemic toxicity in total joint arthroplasty: 9. Ahmadi S, Muth-Selbach U, Lauterbach A, et al. Facili- venous perioperative lidocaine infusion for postoper- incidence and risk factors in the United States from tation of spinal NMDA receptor currents by spillover of ative pain and recovery. Cochrane Database Syst the National Inpatient Sample 1998-2013. Reg Anesth synaptically released glycine. Science 2003;300: Pain Med 2018;43:131–137. 2094–2097. Rev 2015:CD009642. 24. Di Gregorio G, Neal JM, Rosenquist RW, et al. Clinical 10. Daykin H. The efficacy and safety of intravenous lido- 17. Groudine SB, Fisher HA, Kaufman RP, Jr., et al. Intrave- presentation of local anesthetic systemic toxicity: a caine for analgesia in the older adult: a literature nous lidocaine speeds the return of bowel function, review. Br J Pain 2017;11:23–31. decreases postoperative pain, and shortens hospital review of published cases, 1979 to 2009. Reg Anesth Pain Med 2010;35:181–187. 11. Terkawi AS, Tsang S, Kazemi A, et al. A clinical com- stay in patients undergoing radical retropubic prosta- parison of intravenous and epidural local anesthetic tectomy. Anesth Analg 1998;86:235–239. 25. Dunn LK, Durieux ME. Perioperative use of intrave- for major abdominal surgery. Reg Anesth Pain Med 18. Rinder C, Fitch J. Amplification of the inflammatory nous lidocaine. Anesthesiology 2017; 126: 729–737. 2016;41:28–36. response: adhesion molecules associated with plate- 26. Eipe N, Gupta S, Penning J. Intravenous lidocaine for 12. Staikou C, Avramidou A, Ayiomamitis GD, et al. Effects let/white cell responses. J Cardiovasc Pharmacol acute pain: an evidence-based clinical update. BJA of intravenous versus epidural lidocaine infusion on 1996;27 Suppl 1:S6–12. Education 2016; 16: 292–298.

LETTER TO THE EDITOR: A Bad System Will Beat A Good Person Every Time

To the Editor: the resident’s choice of an accepted, but unfa- In Response: miliar technique. From a human factors engi- I read with interest the recent letter “Flip- I thank the editors for neering perspective, her solution: expect the Flops and Spinal Catheters” published in the allowing me to reply to Dr. resident to use better judgement in the future, February 2018 APSF Newsletter. In it, Dr. Schlo- Norris’s comments. I agree with the quote indicat- 1 emerkemper presents some practical system should be reconsidered. In fact, a closer look ing that a good person can be beaten by a bad issues related to a resident placing a spinal might reveal a system error being lack of super- system. Supervision can help defeat the odds catheter after an accidental dural puncture vision. I wonder, should we as anesthesia pro- and prevent a negative outcome. Nevertheless, during placement of a labor epidural at her fessionals treat the induction of labor epidural the scenario I described highlights an issue that institution. Dr. Schloemerkemper focused on analgesia like we treat the induction of every is independent of training experience or supervi- other anesthetic and require an attending anes- sion. If we want to improve a “bad system,” we thesiologist to be in the room? I believe our job have to identify it first. We also need to recognize is to teach residents how to navigate unfamiliar that our work environment might differ from what we have read in the literature. Critically reflecting situations, and laboring parturients deserve the on the circumstances is something that needs to same level of care as surgical patients. be encouraged, not just during residency but Mark C. Norris, MD beyond. We have used the described scenario Chief of Obstetric Anesthesia as a catalyst to create local guidelines regarding Clinical Professor of Anesthesiology intrathecal catheter use. Boston Medical Center Nina Schloemerkemper, MD, FRCA Boston, MA Assistant Clinical Professor Director of Neuroanesthesia Rotation Dr. Norris has no disclosures to report. Department of Anesthesiology and Pain Medicine REFERENCE UCDavis Medical Center, Sacramento, CA. 1. Cobb BT, Lane-Fall MB. Learning from human factors Disclosures: Dr. Schloemerkemper served as a can make anesthesia even safer. Anesth Analgesia consultant for Covidien and Mizuho OSI. 2018;126:382–382. APSF NEWSLETTER June 2018 PAGE 31 Dear SIRS: SAFETY INFORMATION RESPONSE SYSTEM

Defective Pediatric Endotracheal Tubes (ETTs)

Dear SIRS: Dr. Lindsey Loveland Baptist is Assistant Professor in the Department of Anesthesiol- I am writing to report a case of a defective ogy at the Medical College of Wisconsin and pediatric endotracheal tube (ETT) that has Associate Pediatric Anesthesiology Fellow- implications for patient safety. A 14-day-old ship Director at Children’s Hospital of Wiscon- infant was induced intravenously for a sternal sin, Milwaukee, WI. wound irrigation and closure and a 3.5 cuffed endotracheal tube was placed. A circuit leak Dr. Loveland Baptist reports no conflicts of interest. resulted in inadequate ventilation, but despite checking all circuit connections from the Reply: machine to the endotracheal tube it could not Upon receipt, Teleflex visually examined the be readily identified. Adding additional air to endotracheal tube (ETT) and confirmed a hole the endotracheal tube cuff did not percepti- in the tube, as originally reported. Teleflex was bly decrease the leak. Humidifiers tend to be able to reproduce holes in other ETTs by a frequent source of circuit leaks, but all con- excessively pressing the tube against the nections were intact in this case. An audible notch block during the manufacturing process. air leak sound was detected when listening Based on these findings, Teleflex has re- closely to the patient’s airway. Therefore, we Figure 1: This figure depicts the defect hole in the removed the endotracheal tube from the trained all operators, implemented tightened pediatric endotracheal tube near the pilot balloon airway and replaced it. Inspection of the tube sampling for the in-process inspections, entrance point. showed a 3 mm diameter hole in the wall of inspected product in inventory (which found no the tube just proximal to the insertion of the nonconforming devices), and conducted a risk pilot balloon (Figure 1). evaluation as per our internal procedures. Fur- thermore, Teleflex has opened a Corrective We notified the anesthesia technicians who and Preventive Action (CAPA) Project to estab- examined our stock of twelve more tubes with lish long-term corrective actions and prevent the same lot number. Close examination the recurrence of this failure by reducing vari- revealed that the “defect” proximal to the inser- ability in our manufacturing process. tion of the pilot balloon was variable in size and depth in these tubes (Figure 2). Teleflex endeavors to manufacture its At least one of thirty-eight pediatric anes- medical devices to the highest possible stan- thesiologists in our group recalled a similar dards and has comprehensive, active quality incident of difficult-to-isolate circuit leak, and systems in place to assure these standards. it is possible that a similar ETT tube defect We are indebted to you for highlighting this was missed. issue with one of our devices. This report has enabled us to identify an area for improve- An additional tube was found to have the ment in our manufacturing process. We same defect, approximately one and a half regret the occurrence of this incident and ask months after the initial defective ETT was that anyone who experiences such an inci- found. A different lot number from the same dent to please report it to us so that we can manufacturer was noted on the packaging. continuously assess our quality system per- This has led to a complete removal of 3.5 formance and any needs for further investiga- cuffed endotracheal tubes produced by this tion. Patient safety remains the focus of all manufacturer and replacement with another that we do. product. The endotracheal tube defect spe- cific to the manufacturer was submitted to the Lucas B. Elliott FDA and the manufacturer. We hope that this Quality Assurance Lead Figure 2: This figure depicts defect holes within mul- information is helpful to anesthesia profes- Customer Advocate Department tiple pediatric endotracheal tubes near the entrance sionals in a similar scenario. Teleflex Inc. point of the pilot balloon. The holes are of varying diameter.

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. Anesthesia Patient Safety Foundation NONPROFIT ORG. Charlton 1-145 U.S. POSTAGE Mayo Clinic PAID 200 1st Street SW WILMINGTON, DE PERMIT NO. 1858 Rochester, MN 55905

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APSF NEWSLETTER June 2018 PAGE 32

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Rocuronium Current Status of Sugammadex Usage and the 27% Occurrence of Sugammadex-Induced Anaphylaxis In Japan

With Gratitude to Dr. John Eichhorn: An Anesthesia Patient Safety Innovator

Planning Prevents Poor Performance: An Approach to Pediatric Airway Management

Preventing Surgical Site Infection After Cesarean Mitigate Risk Glycemic Maintain Antibiotic Patient Factors Control Normothermia Prophylaxis Education Delivery—The Anesthesia Professional's Role